Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
14E
0F
Potential for minimal harm
0A
0B
0C
May 6, 2026Standard inspection · 6 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and treat residents with respect and dignity for 3 of 12 (Residents # 62, Resident # 45, and Resident # 22 ) residents reviewed for dignity. The facility failed to prevent CNA E from standing over Resident# 62, Resident # 45, and Resident # 22 while assisting residents with eating their meal in the dining area. The facility failed to prevent CNA E from referring to Resident# 62, Resident # 45, and Resident # 22 who needed assistance with meals, as feeders. [...]
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This failure could result in residents not receiving mail in a timely manner and a diminished quality of life.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a sanitary, and comfortable environment for 5 of 20 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], 104 and the East Conference Room) rooms observed for environmental conditions. The facility failed to ensure rooms 101,102, 103, 104 and the East side Conference Room sinks had hot water. These failures could place residents at risk for diminished quality of life, discomfort, and safety.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 3 (Resident #10, Resident # 20 and Resident #25) of 5 residents reviewed for medication administration. The facility failed to ensure the medication error rate (11.5%) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 refrigerator in the secure unit. The facility failed to ensure the refrigerator on the secure unit that was used for patient snack storage was clean and temperatures were being checked and recorded. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #70) of 3 residents reviewed for infection control. The facility failed to implement Enhanced Barrier Precautions for Resident #70 who had an Enhanced Barrier Precautions sign posted on her room door. This failure could affect residents and place them at risk for cross contamination and infections.
December 19, 2025Complaint inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure staff practiced appropriate hand hygiene during meal prep.2. The facility failed to ensure staff wore effective hair restraints while in the kitchen area. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.
April 30, 2025Complaint inspection · 2 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 residents (Resident #'s 2 and 4 ) reviewed for accuracy of records, in that: RN A failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/12/25 during the 6 AM to 6PM shift. RN A failed to document that Resident # 2 had a privacy bag on his catheter bag , a catheter securement device to hold his catheter tubing in place, and that he had a size 16 French to beside drainage and catheter care was administered during the 6 AM to 6 PM shift on 4/12/25. RN B failed to document the wound care for Resident #4's open areas to her right and left buttocks on 4/12/25 during the 6 AM to 6 PM shift. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(Resident # 4) of 2 residents observed for wound care. The facility failed to ensure the wound care nurse washed or sanitized her hands between glove changes while performing incontinent care and wound care on Resident #4. These failures could place residents at risk of infections.
February 27, 2025Standard inspection, Complaint inspection · 8 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain hot water below 110°F for 5 of 8 (Resident #60's sink, RM17 E sink, East Hall shower room sink, Resident #168, Resident #167, and Resident # 14's shared sink and RM [ROOM NUMBER] E sink) bathroom reviewed for water temperature. 1. The temperature of sink in RM [ROOM NUMBER]E was 150°F. 2. The temperature of the East Hall Shower Room Resident 150°F. 3. The temperature of Resident #168, Resident #167, and Resident #14's shared sink was 140°F. 4. The temperature of Resident #60's sink was 136.4°F. 5. The temperature of sink in RM [ROOM NUMBER]E was 125.2°F. 6. The shower water temperature fluctuated, becoming hotter during use for Resident #23 and Resident #1 An Immediate Jeopardy (IJ) situation was identified on 02/25/2025. The IJ template was provided to the facility on [DATE] at 5:00pm. [...]
- E
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on interviews and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bonds reviewed. The facility failed to ensure that the facility's $30,000.00 surety bond was enough to cover the $32,6635 total residents' trust fund account balance. This deficient practice could affect all residents who deposited personal funds with the facility, and place residents at-risk of their personal funds not being assured.
- E
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interviews and record review the facility failed the ensure physician visits were conducted within 2-7 days of admission, once every 30 calendar days for the first 90 calendar days for 3 of 24 residents (Resident #22, Resident #23, and Resident #50) who were review for physician visits. 1. The facility failed to have Resident #22 seen by a physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. 2. The facility failed to have Resident #23 seen by a physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. 3. The facility failed to have Resident #50 seen by physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. This deficient practice could lead to a decline in health status or untreated conditions.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. Hair net was not used for the DA, while he entered the kitchen. 2. Hand hygiene was not performed by CNA-C and the AD while passing trays in the hallway. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interviews, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 10 residents (Resident #50) reviewed for resident rights. The facility failed to obtain a signed consent for admission to reside onto the facility's Memory Care Unit. This failure could affect residents who were placed and received care placed on the Memory Care Unit without informed consent.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #168) of 10 residents reviewed for care plan completion. The facility failed to complete Resident #168's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 5 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion.
January 10, 2024Standard inspection, Complaint inspection · 6 citations
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 3 (Resident #103, Resident #104, and Resident #202) of 8 residents reviewed for care plan completion. The facility failed to complete Resident #103's, Resident #104, and Resident #202 baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff sanitized the thermometer while taking temperature of food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for infection control procedures for 3 of 5 (#4, #17, and #44) residents reviewed for infection control. The facility failed to follow their Infection Control policy regarding CDC guidelines of performing the Flu test in conjunction with their COVID-19 testing. this failure could place residents at risk of the spread of infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 2 of 2 residents (Resident #11 and Resident #42) reviewed for oxygen administration. The facility failed to provide Oxygen (O2) in use sign on resident doorways for Resident #11 and #42. These failures could place residents at risk of not receiving appropriate respiratory care.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual nutritional needs for 1 of 1 lunch meal reviewed. The facility failed to ensure the recipe was followed when prepared pureed Seasoned Greens. This failure could place residents at-risk of inadequate nutrition and weight loss.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident # 8 and Resident # 17) of 5 residents reviewed for resident records. The facility failed to ensure smoking assessments were accurate for Resident #8 and Resident #17. This failure could place residents at risk of having errors in care and treatment.
September 27, 2023Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 1 of 4 staff (CNA-B) reviewed for background screenings. The facility failed to provide evidence of completion of an annual EMR for CNA-B. These deficient practices could place residents at risk for abuse and neglect.
Fire safety inspections
12 fire safety citations on file: 2 on May 6, 2026, 5 on February 27, 2025, 5 on January 10, 2024.
Every fire safety citation12 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 6, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 6, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 10, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 10, 2024 · Corrected (the home has a date of correction)