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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
5D
0E
1F
Potential for minimal harm
0A
0B
0C
September 3, 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 interview and record review the facility failed to ensure a previously implemented fall intervention was in place to reduce the risk of a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 being transferred to the local area emergency room with a left forehead laceration, a left frontal scalp soft tissue hematoma, multiple skin tears and experiencing severe pain.
April 18, 2025Standard inspection · 3 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to perform facial grooming for one of one (R12) resident reviewed for activities of daily living in the sample of 30.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure relieving interventions were utilized as ordered for one (R44) of three residents reviewed with pressure ulcers in a sample of 30.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to document skin changes for a resident on an anticoagulant with known bruises for one (R37) of five residents reviewed for skin conditions in a sample of 30.
August 27, 2024Complaint 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 observation, interview, and record review the facility failed to provide safe transfer for one (R1) of three residents reviewed for transfers in a sample of three. This failure resulted in R1 being sent out to the hospital and suffering from bruising, left elbow hematoma and a head laceration.
April 19, 2024Standard inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident fall interventions were in place and functioning for one of five (R34) residents reviewed for falls in a sample of 26. This failure resulted in R34 having falls and suffering from nasal bone fractures.
- F
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 ensure dietary staff wrote the date on food packages that were newly opened. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: The Department of Health and Human Services Centers for Medicare & Medicaid Services [CMS], CMS Form-671, dated 4/17/2024, document 57 residents reside in the facility. On 4/16/2024, at 9:30 a.m., an initial kitchen tour was conducted with V8/Dietary Staff. During the initial tour, the following frozen-packaged food items were open and undated: chicken wings, chicken strips, pizza topping, vegetable burgers, zucchini slices, carrots, mixed vegetables, and a case of raw biscuits. On 4/16/2024, at 9:30 a.m., V8 confirmed no dates were written on the items. [...]
March 23, 2023Standard inspection · 3 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent employee to resident abuse for one of two residents (R26) reviewed for abuse in the sample of 26. This failure resulted in V3 (CNA/Certified Nursing Assistant) rough handling R26 during cares, resulting in R26 crying and sustaining bruises, a hematoma, and pain to the left arm.
- 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 interview and record review the facility failed to implement care plan goals and interventions for anticoagulant and antidiabetic medications for one resident (R41) of 26 (R41) in a sample of 26.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received individualized treatment and services based on their comprehensive assessment to maintain, improve or prevent further decrease in range of motion for two of 13 residents (R49, R26) reviewed for range of motion in a sample of 26.
Fire safety inspections
5 fire safety citations on file: 3 on April 18, 2025, 1 on April 19, 2024, 1 on March 23, 2023.
Every fire safety citation5 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 18, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 18, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 18, 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 · April 19, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 23, 2023 · Corrected (the home has a date of correction)