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
6D
1E
3F
Potential for minimal harm
0A
1B
1C
July 16, 2026Standard inspection · 5 citations
- F
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to develop a grievance policy, appoint a grievance official, and maintain documentation of the results of all grievances. These deficient practices had the potential to affect all 68 residents who currently resided in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, facility policy review, and review of Occupational Safety and Health Administration (OSHA) guidance, the facility failed to ensure all staff were fit-tested for N95 respirator masks (masks used to protect residents and staff from the transfer of microorganisms that can cause infectious disease) prior to initial use and at least annually thereafter. This deficient practice had the potential to affect all 68 residents who resided in the facility. In addition, the facility failed to ensure a urinary catheter bag was not directly on the floor for 1 (Resident #64) of 1 sampled resident reviewed for catheter use.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a serious mental illness diagnosis for 1 (Resident #10) of 1 resident reviewed for PASARR requirements.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure daily staff postings included the resident census on 3 of 3 days that daily staff postings were observed. In addition, the facility failed to maintain the posted daily nurse staffing data for 18 of 18 months.
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to ensure beneficiary notices were completed with resident name and services provided for informed decision making for 3 (Residents #72, #77, and #78) of 3 sampled residents reviewed for beneficiary notices.
March 26, 2025Standard inspection · 6 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were used: a. when transporting clean linens/laundry; b. when providing catheter care for 1 (#25) of 3 sampled residents who were reviewed for catheter care; and c. to devise and implement a plan to prevent the growth of and monitor for Legionella in the facility. The DON identified 68 residents who resided at the facility, four residents with catheters, and one resident with pressure ulcers.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurate for 2 (#67 and #42) of 2 sampled residents who were reviewed for hospice services. The DON identified five residents who received hospice services.
- 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 interview, the facility failed to ensure a comprehensive care plan included the use of assist bars/side rails for 1 (#28) of 19 sampled residents whose care plans were reviewed. The DON identified 68 residents who resided in the facility.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure assessments for entrapment were completed and informed consent was obtained for the use of assist bars/side rails for 1 (#28) of 1 sampled resident who was reviewed for the use of assist bars/side rails. The DON identified 14 residents who utilized assist bars/side rails in the facility.
- 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, record review, and interview, the facility failed to: a. monitor the temperature of the medication storage room for 1 of 2 medication rooms observed; b. ensure medications were secured for 2 of 6 medication/treatment carts observed; and c. ensure glucose test strips were dated when opened for 2 of 6 medication/treatment carts observed. The DON identified two medication rooms and six medication/treatment carts in the facility.
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure regular inspections of beds and bed rails were completed to identify areas of possible entrapment for 1 (#28) of 1 sampled resident who was reviewed for assist bars/side rails. The DON identified 14 residents who utilized assist bars/bed rails.
November 30, 2023Standard inspection · 1 citation
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to perform fall assessments after falls and initiate interventions to help prevent falls for one (#36) of three sampled residents reviewed for falls. The administrator identified 70 residents residing in the facility.
Fire safety inspections
12 fire safety citations on file: 4 on July 16, 2026, 5 on March 26, 2025, 3 on November 30, 2023.
Every fire safety citation12 citations
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 16, 2026 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · July 16, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 16, 2026 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 16, 2026 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · March 26, 2025 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 26, 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 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 26, 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 · March 26, 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 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 30, 2023 · Corrected (the home has a date of correction)
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 30, 2023 · Corrected (the home has a date of correction)