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
1G
0H
0I
Potential for more than minimal harm
15D
3E
4F
Potential for minimal harm
0A
0B
0C
March 17, 2026Complaint inspection · 1 citation
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's sink in a safe, functional manner for 1 of 3 residents (R1) in the sample of 3.
July 24, 2025Standard inspection · 3 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 observation, interview, and record review, the facility failed to adequately store food items by not properly labeling and/or dating items; and failed to ensure the sanitizing solution was at the recommended level. This failure has the potential to affect all 29 residents currently residing in facility.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were able to operate their televisions for 2 of 2 residents (R31 & R8) reviewed for choices in the sample of 14.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control was maintained and prevent any cross contamination during wound care for 1 of 1 residents reviewed for wounds in the sample of 14.
June 26, 2025Complaint inspection · 2 citations
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview and record review the facility failed to accommodate residents' food preferences and choices for 4 of 6 residents (R2, R3, R5, R6) reviewed for residents' food preferences and choices in the sample of 6.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the breakfast meal was a smooth pureed consistency for 1 of 1 residents (R1) reviewed for pureed diets in the sample of 6.
April 3, 2025Complaint inspection · 2 citations
- F
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on observation, interview, and record review the facility failed to have a full time Activity Director. This applies to all 32 residents in the facility.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide an activity program to meet the individual interests of the residents for 5 or 5 residents (R4, R5,R6,R8,R9) reviewed for activities in the sample of 9.
January 9, 2025Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review the facility failed to ensure two residents (R1, R2) received their evening medications in a timely manner. This applies to 2 of 10 residents (R1, R2) reviewed for nursing care in the sample of 10.
September 11, 2024Standard inspection · 6 citations
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the walk in freezer was repaired and in safe working condition. This failure has the potential to affect all 24 residents residing in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review the facility failed to obtain treatment orders for a resident with a stage 3 pressure injury. This applies to 1 of 2 residents (R5) reviewed for pressure injury in the sample of 12.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary supplements were provided for 2 of 5 residents (R28, R5) reviewed for weight loss in the sample of 12.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to ensure there was no delay in obtaining a medication from the pharmacy and failed to obtain a medication from the pharmacy for 2 of 5 residents (R235 and R11) reviewed for pharmacy services in the sample of 12.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review the facility failed to ensure PRN (as needed) psychotropic medication had a stop date not greater than 14 days for 1 of 5 residents (R11) reviewed for psychotropic medications in the sample of 12.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 1 of 12 residents (R15) reviewed for infection control in the sample of 12.
February 6, 2024Complaint inspection · 1 citation
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family member after the resident experienced a fall. This applies to 1 of 5 (R3) residents reviewed for falls in the sample of 6.
August 3, 2023Standard inspection · 7 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's pain level was controlled. This resulted in the resident experiencing severe pain. This applies to 1 of 2 residents (R138) reviewed for pain in the sample of 17.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure droplet precautions were maintained for residents positive with covid-19 by not keeping doors shut on rooms that were safe to have them shut and ensuring staff wore eye protection when entering a covid-19 positive residents' room. This has the potential to affect all the residents in the facility.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to change a resident's (R14) PICC line dressing as scheduled or as needed and failed to ensure a resident's PICC line end cap was changed weekly. The facility failed to ensure blood glucose monitoring was completed before meals and before residents (R24 & R17) started eating. The facility failed to ensure daily weights were done for residents (R4, R1, R17, R137 & R132). This applies to 7 of 7 residents (R14, R24, R17, R4, R1, R137, & R132) reviewed for quality of care in the sample of 17.
- D
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 a residents safety when the brakes on her wheelchair did not engage completely putting her at risk for falling for 1 of 2 residents (R87) reviewed for safety and supervision in the sample of 17.
- 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 observation, interview and record review, the facility failed to provide catheter care in a manner to prevent infection for 1 of 2 residents (R182) reviewed for catheters in the sample of 17.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an Licensed Practical Nurse did not provide IV (intravenous) care for residents, unless they were IV certified. This applies to 1 of 1 resident (R137) reviewed for competent nurse staffing in the sample of 17.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left at the resident's bedside for 3 of 3 residents (R12, R81, & R137) reviewed for medications in the sample of 17.
Fire safety inspections
26 fire safety citations on file: 7 on July 24, 2025, 3 on October 22, 2024, 9 on September 11, 2024, 7 on August 3, 2023.
Every fire safety citation26 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 24, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 24, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · July 24, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · October 22, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · October 22, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 22, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · September 11, 2024 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · September 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 11, 2024 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · September 11, 2024 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · September 11, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · September 11, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 3, 2023 · 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 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 3, 2023 · Corrected (the home has a date of correction)