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
0G
0H
0I
Potential for more than minimal harm
18D
4E
0F
Potential for minimal harm
0A
1B
0C
November 21, 2025Complaint inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident # 1) reviewed for abuse, the facility failed to ensure staff treated the resident with dignity and respect when the resident did not respond to redirection.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to prevent further potential abuse while the investigation was in progress and failed to suspend the alleged staff member during the investigation in accordance with facility policy.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse or neglect, the facility failed to provide physician order medications as scheduled.
June 26, 2025Standard inspection, Complaint inspection · 8 citations
- E
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on review of clinical records, facility documentation, facility policy, and an interviews for 30 of 52 sampled residents (Resident #1, #3, #4, #5, #6, #8, #13, #14, #15, #18, #23, #24, #26, #28, #29, #30, #33, #35, #39, #42, #44, #58, #500, #501, #502, #503, #504, #505, #506, and #507) reviewed for personal funds, the facility failed to credit interest earned to each resident's personal funds account.
- E
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 facility policy for 3 of 4 sampled residents (Resident #4, Resident #22, and Resident #33) reviewed for advanced directives, the facility failed to obtain a signed copy of an Advanced Directive form for Resident #4 and Resident #33, and for Resident #22 failed to transcribe the signed Advance Directive form to the electronic medical record.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on a review of the clinical record, interviews, facility documentation, and facility policy, for 1 of 3 sampled residents (Resident #28) reviewed for abuse and for the only sampled resident (Resident #30) reviewed for grievances the facility failed to report an allegation of abuse to the State Agency per the requirement.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on a review of the clinical record, interviews, facility documentation, and facility policy, for 1 of 3 sampled residents (Resident #28) reviewed for abuse and for the only sampled residents (Resident #30) reviewed for grievances the facility failed to investigate an allegation of abuse per the facility policy.
- 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 review of clinical record, facility policy, and interviews for the only sampled resident, (Resident #33) reviewed for care planning, the facility failed to ensure the Resident Care Plan was reviewed and revised on a quarterly basis with participation from an interdisciplinary team and Resident #33's representative.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, review of clinical record, facility policy, and staff interviews, the facility failed to ensure fingernail care was provided to Resident #4.
- 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, review of the clinical record, and facility policy for 3 residents identified during the initial screening of residents (Resident # 51, Resident #48 and Resident #21) the facility failed to ensure medications were not at bedside and alcoholic beverages were not stored in the medication refrigerator in 1 of 2 medication refrigerators.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, facility documentation, facility policy and staff interviews, the facility failed to ensure the kitchen ice machine was maintained in sanitary condition. During surveyor walk through of the kitchen on 6/23/2025 at 10:30 AM with Director of Dietary (DD) observation was made of a black substance within the ice machine. Interview and observation with the DD on 6/25/2025 at 11:57 AM identified that the ice machine cleaning would be the responsibility of the Maintenance Director but that the facility currently did not currently have a full time Maintenance Director. Additionally, the DD stated he never thought of looking up into the machine for cleanliness. Subsequent to surveyor inquiry the machine was cleaned by DD and the black residue was no longer present. [...]
September 20, 2023Complaint inspection · 1 citation
- 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, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to ensure staff provided care in accordance with the resident plan of care.
April 20, 2023Standard inspection · 10 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, observation, review of facility's documentation review of policy and interviews for 1 of 3 sampled residents (Resident #32) who was reviewed for falls, the facility failed to remove hazard to prevent a fall with injury and for 1 sampled resident ( Resident # 155) who required assistance with meal, the facility failed to remove a hot beverage lid to prevent an accident and for 1 sampled resident (Resident # 20) with history of dysphagia, the facility failed to cut up the resident's meat to prevent an accident.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #9) reviewed for allegations of mistreatment, the facility failed to ensure the resident was free from staff abuse.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy, and interviews for 1 sample resident (Resident # 37) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to obtain and complete a PASRR level II screening.
- 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 reviews, observations, facility documentation, facility policy and interviews for 1 sampled resident (Resident#51) who was reviewed for pressure ulcer, the facility failed to ensure that a care plan for prevention of skin breakdown was in place for a resident found at risk.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, review of facility policy and interviews for 1 of 5 residents for (Resident #206) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident received assistance with ADL timely.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for 1 of 3 Residents (#32) observed during meals that required feeding assistance by staff, the facility failed to ensure that staff provided one to one assistance to a resident with eating as directed by the physician.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for 1 sampled resident (Resident#51) who was reviewed for pressure ulcer, the facility failed to ensure that a Resident at risk for skin breakdown did not develop a pressure ulcer.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for 1 residents (Resident #25) reviewed for Intravenous Therapy ( IV )therapy, the facility failed to ensure parenteral fluids were administered by qualified, competent and trained staff.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on clinical record review, observations, interviews, and review of facility policy for 1 sampled residents( Resident #51) reviewed for pressure ulcers, the facility failed to ensure that infection control practices for a resident on isolation were followed and for 1 of 3 residents for (Resident# 208) reviewed for toileting/incontinent care, the facility failed to ensure that staff performed proper hand hygiene.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record reviews and interviews for 2 of 2 residents reviewed for hospitalization (Resident #5 and #7), the facility failed to ensure the resident's MDS accurately reflected the residents discharge status at the time of the assessment.
March 1, 2021Standard inspection · 1 citation
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on clinical record review, review of facility policy and interview for 3 of 3 sampled residents (Residents #29, #36 and #41) reviewed for the timeliness of physician's orders, the facility failed to ensure that the routine medication orders were reviewed, renewed, signed and dated every sixty days.
Fire safety inspections
10 fire safety citations on file: 5 on June 26, 2025, 2 on April 20, 2023, 3 on March 1, 2021.
Every fire safety citation10 citations
- D
Provide properly protected cooking facilities.
K 324 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 20, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 20, 2023 · Corrected (the home has a date of correction)
- 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 · March 1, 2021 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · March 1, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 1, 2021 · Corrected (the home has a date of correction)