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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
2E
0F
Potential for minimal harm
0A
0B
0C
December 18, 2025Standard inspection · 8 citations
- E
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 review, staff interview, policy review, and Resident Assessment Instrument manual the facility failed to develop a comprehensive care plan that included behaviors/interventions for residents receiving psychotropic medications( anti-anxiety, antipsychotic, and antidepressants) for 4 of 5 residents reviewed (Residents #3,#6, #2, and #44). The facility reported a census of 55 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, clinical record review, staff interviews and policy review, the facility failed to use proper hand hygiene and infection control practices during medication administration and wound care and further failed to use full Enhanced Barrier Precautions (EBP) during wound care for 1 of 1 residents reviewed (Resident #38) for pressure ulcers. The facility reported a census of 55 residents.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to complete a discharge summary, including a recapitulation of stay, and failed to provide a discharge summary to the resident/family for 1 of 1 residents reviewed for discharge (Resident #65). The facility reported a census of 55 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on electronic health record (EHR) review and staff interviews, the facility failed to transcribe and initiate a physician order for Sertraline on 1 of 5 residents reviewed for medications (Resident #44). The facility reported a census of 55.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and staff interviews, the facility failed to provide services to protect the resident from accident or hazards by transporting a resident in a wheelchair without foot pedals (Resident #48 ). The facility reported a census of 55.
- 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, staff interviews and policy review, the facility failed to store medications in a safe manner when the medication cart was unlocked and not within eyesight of the Registered Nurse (RN) responsible for the cart. The facility reported a census of 55 residents.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, facility policy, and the Food and Drug Administration (FDA) food code the facility failed to prepare food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness when a staff member failed to cover facial hair (beard and mustache) while preparing food. The facility reported a census of 55 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on electronic health record (EHR) review, resident interview, and staff interview, the facility failed to document and update resident records related to a change in medical condition due to an urinary tract infection (UTI) for 1 of 17 records reviewed (Resident #10). The facilty reported a census of 55.
January 23, 2025Standard 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 observation and staff interviews, the facility failed to maintain dignity for 1 of 17 residents reviewed (Resident#2). The facility reported a census of 52.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to accurately code the federally mandated Minimum Data Set (MDS) assessment for 1 of 17 residents reviewed in the sample (Resident#24). The facility reported a census of 52.
- 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 staff interviews, family interviews, observation and record review, the facility failed to update individual Care Plans for 3 of 19 reviewed (Residents #20, #22, and #38). The facility failed to revise Care Plans for R#20 for Hospice services and failed to update R#22, R#28 for wanderguard (device to alert/inhibit elopements). The facility reported a census of 52 residents.
March 28, 2024Standard inspection · 1 citation
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to refer one of one residents with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who were later identified with newly evident or possible serious mental disorder or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination (Residents #17). The facility reported a census of 51 residents.
Fire safety inspections
21 fire safety citations on file: 4 on December 18, 2025, 6 on January 23, 2025, 11 on March 28, 2024.
Every fire safety citation21 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 18, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 18, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 18, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · December 18, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 23, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 23, 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 · January 23, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 23, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 23, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 23, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 28, 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 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 28, 2024 · 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 · March 28, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 28, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 28, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 28, 2024 · Corrected (the home has a date of correction)