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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
0B
0C
June 4, 2026Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review the facility failed to ensure that residents who require assistance receive a shower for 2 (R20 and R1) of 3 residents reviewed for Activities of Daily Living in the sample of 20. This past non-compliance occurred between 4/1/26 and 5/26/26.1. R20's admission Record dated 6/2/26 documented an admission date of 2/18/26 and included diagnoses of fracture of left femur, dementia, lack of coordination, reduced mobility and generalized muscle weakness. R20's most recent Care Plan documents a focus area for self-care deficit dated 2/23/26. Interventions for this focus area include assisting with ambulation and transfers, assisting with toileting and showering/bathing both dated 2/23/26. R20's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R20 has severe cognitive impairment. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to ensure wound treatments were completed as ordered by the physician for 3 of 3 residents (R1, R19 and R20) reviewed for pressure ulcers in the sample of 20. This past non-compliance occurred between 4/1/26 - 5/26/26.1. R1's admission Record with print date of 6/2/26 documented an admission date of 3/28/26 and included diagnoses of infection and inflammatory reaction due to other cardiac vascular devices implants and grafts and end stage renal disease. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is at risk for developing pressure ulcers and that he has two unhealed pressure ulcers that are unstageable. The MDS documents treatments for these unhealed pressure ulcers include the application of ointments/medications and pressure ulcer care. [...]
May 26, 2026Complaint 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, observation, and record review the facility failed to provide the identified level of supervision and assistance required to prevent an accident for 1 of 3 (R1) residents reviewed for accidents in a sample of 9. This failure resulted in R1 falling and having multiple rib fractures. This past noncompliance occurred on 05/06/26.
September 25, 2025Standard inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal protective equipment was worn per current standards of practice for 5 of 9 (R5, R34, R44, R57, R76) residents reviewed for transmission-based precautions in the sample of 33. Findings Include:1. R34's admission Record with a print date of 09/25/2025 documents R34 was admitted to the facility on [DATE] with diagnoses that include heart failure and hypertension. R34's MDS (Minimum Data Set) dated 7/4/2025 documents R34 has a BIMS (Brief Interview for Mental Status) score of 07, indicating R34 has a severe cognitive deficit. R34's Order Summary Report dated 09/25/2025 documents a physician order dated 9/22/25 of, Isolation, due to covid positive, per facility protocol. R34's current Care Plan did not document a Focus area related to Covid 19 and/or transmission-based precautions. 2. [...]
October 31, 2024Standard inspection · 4 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide showers or bathing alternative, twice per week for 2 (R7 and R56) of 3 residents reviewed for showers in a sample of 36.
- 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 restorative programs were implemented to prevent a decline in condition for one of one residents (R35) reviewed for position/mobility in the sample of 36. Findings Include: R35's admission Record with a print date of 10/31/24 documents R35 was admitted to the facility on [DATE] with diagnoses that included heart failure, heart disease, insomnia, and obstructive and reflux uropathy. R35's Minimum Data Set (MDS) dated [DATE] documents R35 had a BIMS (Brief Interview for Mental Status) score of 04, which indicates R35 has a severe cognitive deficit. This same MDS does not document any restorative programs or physical therapy. On 10/29/24 at 11:27 AM, V9 (Licensed Practical Nurse/LPN) was observed administering medication to R35. R35 was tearful. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review and observation, the facility failed to implement planned fall interventions for 2 (R7 and R52) of 7 residents reviewed for falls in a sample of 36.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a plan of care for a resident with Dementia that included appropriate treatment and services to attain or maintain the highest practicable well being for 1 (R77) of 3 residents reviewed for dementia care in a sample of 36.
January 23, 2024Complaint inspection · 1 citation
- 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 timely physician notification of a change in a pressure wound, clarify changes in wound treatment orders, and administer treatments as ordered for a pressure wound for 1 (R1) of 3 residents reviewed for wound care in the sample of 3.
September 28, 2023Standard inspection · 0 citations
Fire safety inspections
26 fire safety citations on file: 9 on September 25, 2025, 10 on October 31, 2024, 7 on September 28, 2023.
Every fire safety citation26 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 25, 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 · September 25, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 25, 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 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 31, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · September 28, 2023 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · September 28, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 28, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · September 28, 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 · September 28, 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 · September 28, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 28, 2023 · Corrected (the home has a date of correction)