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 22 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
2E
2F
Potential for minimal harm
0A
0B
0C
October 29, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were carried out timely for 1 of 3 residents reviewed for urinary tract infection. (Resident B).
June 9, 2025Standard inspection · 1 citation
- 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 store food in a sanitary manner related to undated and unlabeled foods and drinks for 1 of 1 kitchen areas observed. (Main kitchen) This issue had the potential to affect 82 of 83 residents who consumed food from the kitchen.
May 8, 2025Complaint inspection · 2 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse resolution was followed regarding care assignments for 1 of 3 residents reviewed for abuse. (Resident C)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to follow a physician's order when administering blood pressure medication for 1 of 6 residents reviewed for quality of care. (Resident E)
July 29, 2024Standard 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 store and prepare food in a sanitary manner related to expired leftovers, open and undated food in the walk-in cooler and skillets with missing Teflon for 1 of 1 kitchens reviewed. This had the potential to affect 69 of 69 residents who received their meals from the kitchen.
- 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 develop a care plan regarding communication needs for 1 of 1 residents reviewed for Communication and Sensory Needs (Resident 39) and accident hazards for 1 of 1 residents reviewed for Accidents. (Resident 56)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, observation and record review, the facility failed to keep ensure Resident 56's environment was free of potential hazards for 1 of 1 resident reviewed for environmental hazards. (Resident 56)
August 14, 2023Standard inspection · 15 citations
- E
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 observation, record review and interviews, the facility failed to ensure a care plan meeting was conducted timely and care plans revised timely for 4 of 19 residents reviewed for careplanning. (Resident 15, 39, 58 and179)
- 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, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety. This deficient practice had the potential to affect the 80 of 82 residents who received food from the kitchen.
- 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 interview and record review, the facility failed to ensure the Physician Orders for Scope of Treatment (POST) form matched the Physician order for 1 of 82 residents whose Advanced Directives were reviewed (Resident 232).
- 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 record review and interview, the facility failed to ensure that transfer and discharge paperwork was completed and given to a resident or family members and failed to notify the ombudsman in a timely manner of resident's discharge from the facility for 1 of 1 residents reviewed for notification of discharge. (Resident 76) Finding Includes: A record review was conducted on 8/14/23 at 2:49 P.M., for Resident 76. Diagnoses included, but were not limited to: urinary tract infection, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, malignant neoplasm of uterus, inflammatory disease of uterus. An admission MDS (Minimum Data Set) assessment, date 5/8/2023, indicated the resident was cognitively intact. A Discharge MDS assessment, dated 7/11/2023, indicated the resident had been discharged with an anticipated return to facility. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the comprehensive assessment was accurate and completed for 2 residents reviewed for dental status and bowel and bladder continence . (Resident 1 &51)
- 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, record review and interviews, the facility failed to ensure care plans were developed for 2 of 19 residents reviewed for care planning. (Residents 1 for dental care and Resident 15 Diabetes, Diuretic, anithypertensive and Vitamin D medication use)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure nail care was provided for 1 of 6 residents reviewed for Activities of Daily Living (ADL) needs. (Resident 20)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 1 of 1 residents reviewed for Hospice services, received coordinated care between Hospice and the facility. (Resident 15)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a resident had interventions in place to prevent the development of a DTI (deep tissue injury) skin area for 1 of 4 residents reviewed for pressure ulcers. (Resident 39)
- 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 ensure a resident received appropriate care of a nephrostomy tube and foley catheter and Physician Orders for treatment for 1 of 1 residents reviewed for urinary and nephrostomy catheter. (Resident 179)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was stored and maintained per professional standards and signage was on the door for 2 of 2 residents reviewed for respiratory care. (Resident 68)
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to initiate physician signed pharmacy recommendations to decrease a pain medication in a timely manner for 1 of 5 residents reviewed for unnecessary medications. (Resident 39)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the medication regimen was free from unnecessary medication for 2 of 5 residents reviewed for medication use. (Resident 15 regarding monitoring of medications and 51 regarding antibiotic use)
- 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 record review and interview, the facility failed to ensure a Pharmacy Recommendation and Physician's Order, to gradually reduce an antipsychotic medication, was implemented timely for 1 of 5 residents reviewed for medication use. (Resident 15)
- 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 observation, interview and record review, the facility failed to ensure medications were dated when opened, failed to store wound cleanser away from medications, failed to ensure medication carts were free of loose pills and failed to ensure residents alcohol bottles were labeled with resident identifiers in 3 of 3 medication carts and 1 of 1 medication rooms observed. ( F/D Medication cart, B Medication cart, Memory Care Medication cart and the Long Term Medication room)
Fire safety inspections
41 fire safety citations on file: 24 on June 9, 2025, 8 on July 29, 2024, 9 on August 14, 2023.
Every fire safety citation41 citations
- F
Establish staff and initial training requirements.
E 37 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · June 9, 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 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 9, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · June 9, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 9, 2025 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · June 9, 2025 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · June 9, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 29, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · July 29, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 29, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 29, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 29, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 29, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · July 29, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · July 29, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 14, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 14, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 14, 2023 · 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 · August 14, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 14, 2023 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · August 14, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 14, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 14, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · August 14, 2023 · Corrected (the home has a date of correction)