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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
14D
5E
1F
Potential for minimal harm
0A
0B
1C
April 9, 2026Standard inspection, Complaint inspection · 7 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to serve food at a safe, preferred temperature and palatable. The facility reported a census of 111 residents.
- 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, staff interviews and policy review the facility failed to ensure kitchen equipment and floors are maintained in a clean and sanitary manner, open food items dated, and expired food items discarded. The facility reported a census of 111 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure laundry was processed and transported in a safe and sanitary manner in a hallway with 31 residents and in the laundry room. The facility staff also failed to wear appropriate protective equipment when soiled laundry was sorted. The facility reported a census of 111 residents.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to implement their policy to prohibit and report allegations of abuse of a resident for 1 of 1 resident (Resident #72) reviewed for abuse. The facility reported a census of 111 residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to revise a care plan to ensure resident safety with a visitor after allegations of abuse had been identified for 1 of 1 residents (Resident #72) reviewed for care plans. The facility reported a census of 111 residents.
- 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, staff interviews, and facility policy review the facility failed to properly store and secure resident safety and accessibility of a medication cart by leaving it unlocked and accessible to residents during medication pass near the main dining room. The facility identified a census of 111 residents.
- 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, clinical record review, resident interview, family and staff interviews, the facility failed to ensure the resident received food in a consistency based on physician orders for 1 of 2 residents (Resident #86) reviewed for therapeutic diet. The facility reported a census of 111 residents.
December 30, 2025Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to ensure medications available for administration as ordered for 1 of 3 residents (Resident #3). Resident #3 missed a total of four doses of medications due to two medications not be available in the facility. The facility reported a census of 105 residents.
September 17, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide appropriate supervision when a staff failed to use a gait belt to ensure each resident safety during a transfer for 1 of 3 residents reviewed (Resident #1) for safety. Resident #1 fell during the transfer which resulted in a left arm and wrist fracture. The facility reported a census of 109 residents.
April 17, 2025Standard inspection · 1 citation
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to re-submit a Pre-admission Screening and Resident Review (PASARR) for a stay longer than 60 days for 1 of 3 residents reviewed. The facility reported a census of 88 residents.
March 18, 2025Complaint inspection · 2 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record review, resident interview and facility policy review the facility failed to implement care plans for two (2) of three (3) residents reviewed (Resident #2 and #3). The facility reported a census of 101 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, clinical record review, facility policy review, provider, resident and staff interviews, staff interview the facility failed to follow physician orders for three (3) of three (3) residents reviewed (Resident #1, #2 and #3). The facility identified a census of 101 residents.
July 2, 2024Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, clinical record review, family and staff interviews, the facility failed to respect a resident's right to request a transfer to the emergency room for an evaluation related to blood in stool for 1 of 1 residents (Resident #7) reviewed. The facility reported a census of 81 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, clinical record review, family and staff interviews, the facility failed to provide timely assessment and intervention for 1 of 2 residents (Resident #7) taking an anti-coagulant medication and voicing concern due to multiple episodes of diarrhea and blood in an incontinent brief. The facility reported a census of 81 residents.
May 16, 2024Standard inspection, Complaint inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to implement and modify interventions, and provide safety to 1 of 3 residents reviewed for falls (Resident #67) who fell repeatedly at the facility and sustained two (2) fractures. The facility reported a census of 94 residents.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, policy review, and staff interviews the facility failed to keep the kitchen free of flies, keep garbage cans covered, keep bare hands off the drinking surface of the glass, keep the kitchen surfaces clean, store food items at the correct temperatures, keep stored foods dated and closed, keep bare hands off of food, and use gloves correctly during food preparation. The facility reported a census of 94 residents.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, policy review, and staff interview the facility failed to bring foods to the correct temperature prior to serving residents and keep it at the correct temperature throughout meal service to serve food and drink that is palatable, attractive, and at a safe and appetizing temperature. The facility reported a census of 94 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, policy review, and staff interviews the facility failed to keep the resident in clean clothes and with a clean face after every meal in order to maintain dignity for 1 of 3 resident reviewed (Res #51). The facility reported a census of 94 residents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, clinical record review, staff interviews and policy review the facility failed to provide adequate incontinent cares for 3 out of 3 residents reviewed (Resident #49, #71 and #74). The facility identified a census of 92 residents.
- C
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on staff interviews, facility record review and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey and cited in previous surveys. The facility reported a census of 94 residents.
March 27, 2024Complaint 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, staff interview, and facility policy review the facility failed to restrain hair for 2 of 2 meals observed. The facility reported a census of 88 residents.
January 3, 2024Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to provide eating assistance in a timely and appropriate manner, for residents dependent on staff for feeding assistance during 1 of 3 meal observations, for 1 of 2 residents observed in the open sample that required feeding assistance (Resident #4). The facility reported a census of 90 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool dated 12/12/23, documented Resident #4 with diagnoses that included non-Alzheimer's dementia, malnutrition, anxiety and depression, completely dependent on staff for eating, with weight recorded at 102 pounds and received a mechanically altered texture diet. Review of Resident #4's Weight Record, revealed the following entries entered in pounds: a. On 6/9/23 - 107.2 b. On 7/10/23 -102.8 c. On 8/3/23 -100.8 d. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, and staff and resident interviews, and facility policy review, the facility failed to provide accurate and timely assessments, failed to implement appropriate interventions, failed to notify the physician of resident condition changes that included absence of bowel movements, nausea with loss of appetite and the resident's refusal of insulin administration, and resulted in the resident's hospitalization for fecal impaction. Upon the resident's return from the hospital, the facility failed to follow Physician Orders that addressed the continued fecal impaction, failed to notify the physician the resident refused the prescribed bowel regimen treatment, and resulted in the resident's required treatment in a hospital emergency room for acute abdominal pain related to the worsened fecal impaction. [...]
Fire safety inspections
10 fire safety citations on file: 3 on April 9, 2026, 3 on April 17, 2025, 4 on May 16, 2024.
Every fire safety citation10 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · April 9, 2026 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 9, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · April 9, 2026 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 16, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · May 16, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 16, 2024 · Corrected (the home has a date of correction)