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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
1E
0F
Potential for minimal harm
0A
0B
0C
June 16, 2026Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 3 of 3 residents reviewed for respect and dignity. (Resident C, D and E)
December 18, 2025Standard inspection, Complaint inspection · 4 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's representative received notification in writing of the facility's bed hold policy, the Ombudsman was notified when a resident's was transferred and discharged to the hospital, and discharge paperwork provided to a resident's caregiver did not contain another resident's information for 2 of 3 residents reviewed for discharge. (Resident 37 and C)
- 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 Abnormal Involuntary Movement Scale (AIMS) assessments were completed and daily weights were obtained for 2 of 2 residents reviewed for quality of care. (Resident 21 and 46)
- 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 a medication cart was locked when not in direct observation of staff for 1 of 4 medication carts randomly observed for medication storage. (300 hall medication cart)
- 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 personal protective equipment (PPE) into an enhanced barrier precaution (EBP) room while providing care for 1 of 5 residents reviewed for enhanced barrier precautions. (Resident 46)
October 2, 2024Standard inspection · 3 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct personal protective equipment (PPE) for contact precautions was used, to perform hand hygiene after resident contact, to utilize enhanced barrier precautions (EBP) when required, to protect clean laundry from contamination, to perform hand hygiene and change gloves while performing wound care, and to keep the indwelling catheter tubing from touching the floor for 7 of 7 residents reviewed for infection control. (Resident 19, 33, 47, 18, 20, 38 and 48)
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure the physician was notified timely of a choking episode for 1 of 1 resident reviewed for respiratory infection. (Resident 12)
- 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 the correct amount of oxygen was administered as ordered by the physician for 1 of 1 resident reviewed for respiratory care. (Resident 54)
July 12, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member treated residents with respect and dignity while providing Activities of Daily Living (ADL) care for 3 of 5 residents being reviewed for ADL care. (Resident B, G and H) The deficient practice was corrected on 12/28/23, prior to the start of the survey, and was therefore past noncompliance.
October 11, 2023Complaint inspection · 1 citation
- 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 resident with a diagnosis of Alzheimer's disease who was a known risk for an elopement was kept safe from eloping from the facility property for 1 of 1 resident being reviewed for elopement. (Resident B) The deficient practice was corrected on 9/30/23, prior to the start of the survey, and was therefore past noncompliance.
August 7, 2023Standard inspection · 6 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. During an observation, on 8/1/23 at 1:55 p.m., Resident 362 was sitting up in a chair and had a red open area on her right shin without a dressing. During an observation, on 8/3/23 at 10:42 a.m., the resident was sitting up in a chair with a dressing to her right shin covering up the open area. The record for Resident 362 was reviewed on 8/3/23 at 10:30 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, and congestive heart failure. An admission nursing assessment, dated 7/25/23 at 2:30 p.m., indicated the nurse noted multiple wounds on the resident's legs and feet. The nurse who completed the assessment had put the wound notes in the comment section instead of the wounds section. A physician's order, dated 8/3/23, indicated the facility was to do wound care to both feet and legs every day and as needed. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a significant weight loss and to ensure the resident received nutritional interventions in a timely manner for 1 of 5 residents reviewed for nutrition. (Resident 45)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to assess and document the post dialysis and daily observation for 1 of 1 resident reviewed for dialysis. (Resident 22)
- D
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to ensure the mandatory submission of staffing information, Payroll Based Journal (PBJ), was electronically submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for the 2nd Quarter of 2023. (1/1/2023-3/31/2023)
- 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 gloves when performing a blood glucose check for 1 of 5 residents reviewed for medication administration. (Resident 29)
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received the pneumococcal immunization and/or notified the physician when the resident or resident's representative had questions or concerns for 1 of 5 residents reviewed for immunizations. (Resident 6)
Fire safety inspections
12 fire safety citations on file: 2 on December 18, 2025, 6 on October 2, 2024, 4 on August 7, 2023.
Every fire safety citation12 citations
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 18, 2025 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · December 18, 2025 · Corrected (the home has a date of correction)
- F
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
K 224 · October 2, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 2, 2024 · Corrected (the home has a date of correction)
- E
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 · October 2, 2024 · 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 · October 2, 2024 · 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 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 7, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 7, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 7, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 7, 2023 · Corrected (the home has a date of correction)