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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
3E
1F
Potential for minimal harm
0A
0B
0C
March 9, 2026Standard inspection, Complaint inspection · 8 citations
- 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, staff interviews, and review of facility food safety policy, the facility failed to ensure food and food preparation services were protected from potential contamination. This had the potential to affect all residents in the facility that received food from the kitchen, except one resident (#95) with an active NPO (nothing by mouth) order during the survey. The facility census was 78.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations, staff interviews, and review of a facility recipe for pureed food, the facility failed to ensure pureed food was prepared to the proper consistency and texture before serving the food to residents. This had the potential to affect seven (#15, #17, #7, #21, #26, #43, and #61) residents identified by the facility with pureed texture dietary orders. The facility census was 78.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on medical record review and staff interview, and family interviews, the facility failed to provide a written notification of a room change. This affected one (#95) of one residents reviewed for room changes. The facility census was 78.
- D
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 medical record review, observation, family interview, staff interview, and facility policy, the facility failed to maintain a clean and home-like environment. This affected one (#93) of two residents review for the physical environment. The facility census was 78.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide assessments and monitoring of a resident who tested positive for Coronavirus Disease 2019 (COVID-19). This affected one (#92) of one residents reviewed for COVID-19. The facility census was 78.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to complete a proper bed rail assessment, including measurements of the air mattress and obtaining proper consent. This affected one (#96) out of one residents reviewed for siderails. The facility census was 78.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents did not receive unnecessary medications, when one resident received antibiotics without a an adequate indication for use. This affected one (#10) out of six residents reviewed for unnecessary medications. The facility census was 78.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, staff interview, and facility policy, the facility failed to ensure behaviors were documented in a resident's medical record. This affected one (#95) out of three residents reviewed for medical record documentation. The facility census was 78.
November 19, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, policy review, witness statements, physician notes and staff interviews, the facility failed to prevent sexual abuse of one Resident (#11) of three reviewed. The facility census was 82.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents residing in a secure memory care unit were observed when outside the unit. This affected one Resident (#10) of three reviewed. The facility census was 82.
February 20, 2025Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review, staff interview, and policy review the facility failed to ensure a resident was sent out to the hospital in a timely manner after a fall with a fracture. This affected one (#90) of three residents reviewed for falls. The facility also failed to ensure incontinent care was provided per standard this affected one, (#38) of three reviewed for incontinent care and had the potential to affect the 58 residents the facility identified as being incontinent. The census was 89.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure an X-ray was ordered and implemented in a timely manner. This affected one (#90) of three residents reviewed for X-rays. The census was 89.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observations, staff interview and policy review the facility failed to ensure proper infection control was maintained during incontinence care. This affected one (#38) of three residents reviewed for incontinence. The facility identified there were 58 residents who were incontinent. The census was 89.
September 3, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to follow physician orders for wound care dressing. This affected one (Resident #85) of three residents reviewed for wound care. The facility census was 83.
December 27, 2023Complaint inspection · 2 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of Self-Reported Incidents, and staff interviews the facility failed to ensure resident medications were not misappropriated. This affected two (Residents #32, #84) of three reviewed for misappropriation. The facility census was 80.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure medications were given as ordered. This affected one (Resident #32) of three residents reviewed for medication administration. The facility census was 80.
March 16, 2023Standard inspection · 13 citations
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and staff interview, the facility failed to provide specific and specialized training staff working on the Memory Care unit. This had to potential to affect 15 (#11, #22, #23, #30, #40, #44, #47, #48, #49, #52, #53, #54 ,#58, #324 #325) of 15 residents residing on the Memory Care unit. The facility census was 78.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure residents needs were met by answering call lights in a timely manner. This affected two (#124 and #126) of two residents reviewed for call lights. The facility census was 78.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to honor a resident's choice and physician order related to advance directives. This affected one (#73) of three residents reviewed for advance directives. The facility census was 78.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, resident and staff interviews, and policy review, the facility failed to complete an investigation related to potential misappropriation of a resident's personal belongings. This affected one (#46) of three residents reviewed for potential misappropriation. The facility census was 78.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on review of the medical record and staff interview, the facility failed to ensure residents were screened for Preadmission Screening and Resident Review (PASARR) services upon admission and after new diagnoses for serious mental illness. This affected two(#36 and #59) of two residents reviewed for PASARR. The facility census was 78.
- 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 observation, medical record review, staff and resident interview, the facility failed to develop a care plan to meet a resident's dental needs. This affected one (#41) of 24 residents reviewed for care plans. The facility census was 76.
- 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 medical record review, resident and staff interviews, and policy review, the facility failed to hold timely care conferences. This affected two (#21 and #36) of 24 residents reviewed for care conferences. The facility census was 78.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure treatments were completed as ordered and obtain orders for a treatment. In addition, the facility failed to clean scissors prior to use and perform hand hygiene during wound care. This affected two (#6 and #46) of six residents reviewed for wound treatments. The facility census was 78.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, staff interview and policy review, the facility to ensure wounds were assessed and staged timely and failed ot ensure pressure relieving devices were in place to prevent skin impairments. This affected two (#34 and #11) of five reviewed for pressure ulcers. The facility identified there were five pressure ulcers in the facility. The facility census was 78.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observations, and staff interviews, the facility failed to implement fall prevention interventions for a resident. This affected one (#286) of one resident reviewed for accidents. The facility census was 78.
- 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 medical record review, observation, staff interview, and policy review, the facility failed to provide care and treatment for incontinence care and ensure hand washing was completed post care. This affected one (#34) of one resident reviewed for incontinence care. The facility identified there was 51 incontinent residents. The facility census was 78.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure a resident received required dental services to meet the residents dental needs. This affected one (#41) of two residents reviewed for dental care. The facility census was 78.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, staff interview, the facility failed to ensure residents meals do not include food identified as an allergy. This affected two (#21 and #42) of two residents reviewed for food allergies. The facility census was 78.
February 12, 2020Standard inspection · 8 citations
- E
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 observation, review of the facility's policy and staff interview, the facility failed to ensure a medication cart was locked. This had the potential to affect twenty-three of twenty-five residents who were independently mobile residing on the west hallway. The facility census was 75.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the physician was notified of a resident's significant weight loss in a timely manner. This affected one (#35) of four residents reviewed for weight loss. The facility identified 10 residents with weight loss.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on medical record review, staff interviews, review of the facility's Self-Reported Incident and review of the facility's abuse policy, the facility failed to implement their abuse policy by not thoroughly investigating an allegation of abuse and reporting an allegation of abuse to the State Survey Agency. This affected one (#35) of one resident reviewed for abuse. The facility census was 75.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, staff interview, review of the facility's Self-Reported Incident and policy review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency. This affected one (#35) of one resident reviewed for abuse. The facility census was 75.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated. This affected one (#35) of one resident reviewed for abuse. The facility census was 75.
- 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 observation, staff interview and record review, the facility failed to develop a person-centered plan of care for a resident who received oxygen. This affected one (Resident #32) of eighteen residents reviewed during the annual survey. The facility census was 75.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on record review, observation, review of the facility's policy and staff interview, the facility failed to hold activities that met the needs of the residents residing on the memory care unit. This affected three (Resident #10, #11, and #63) of three residents reviewed for activities. This had the potential to affect all 11 residents residing on the memory care unit. The facility census was 75.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review, interview with staff and resident and policy review, the facility failed to ensure adequate supervision of a resident who had a history of smoking in the facility. This affected one (#6) of two residents reviewed for smoking. The facility identified eight residents who were independent smokers.
Fire safety inspections
12 fire safety citations on file: 2 on July 24, 2026, 5 on March 16, 2023, 5 on February 12, 2020.
Every fire safety citation12 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 24, 2026 · Not yet corrected
- F
Provide a written emergency evacuation plan.
K 711 · July 24, 2026 · Not yet corrected
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 12, 2020 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 12, 2020 · 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 12, 2020 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 12, 2020 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 12, 2020 · Corrected (the home has a date of correction)