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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
6E
0F
Potential for minimal harm
0A
0B
0C
April 2, 2026Standard inspection · 10 citations
- E
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 the residents' environment remained free of accident hazards for the main dining room by failing to secure hazardous cleaning chemicals in a resident non-accessible area.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program to eradicate common household pests.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had a clean, homelike environment for 1 of 3 units.
- 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 provide a bed hold notice for 1 of 3 residents, Resident #138, reviewed for hospitalizations.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 4 residents, Resident #2, reviewed for respiratory 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, interview, and record review, the facility failed to ensure the implementation of person-centered comprehensive care plans for 1 of 6 residents, Resident #89, reviewed for safety concerns.
- 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 ensure the provision of necessary care and services of medication administration to maintain appropriate blood pressure control for 1 of 1 resident, Resident #111, reviewed for surgical coordination.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents, Resident #11, reviewed for medication pain management.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review the facility failed to ensure all residents were free from unnecessary medications for 1 of 5 residents, Resident #80, reviewed for unnecessary medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the possible spread of infection for respiratory equipment for 3 of 4 residents, Residents #2, #12, and #54, reviewed for respiratory services.
October 24, 2024Standard inspection · 7 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen's walk-in cooler, walk- in freezer, and in 2 of 3 nutrition rooms and appliances for preparing food were kept in a clean, sanitary manner in 1 of 3 nutrition rooms.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record reviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #54) of 3 residents reviewed for skin conditions.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record reviews, the facility failed to ensure 2 of 7 residents, (Resident #83 and Resident #107) reviewed for Preadmission Screening and Resident Review (PASRR) documented all diagnoses relevant to the screening.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #10) of 3 residents reviewed for skin conditions.
- 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 observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in a secured manner for 2 of 3 halls.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accurately document wound care dressing changes for 1 (Resident #10) of 3 residents reviewed for skin conditions.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to perform hand hygiene during wound care for 1 (Resident #10) of 3 residents reviewed for skin conditions and during meal delivery.
June 23, 2023Standard inspection · 9 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards for 2 of 3 residents, Residents #90 and #105.
- E
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 all drugs were stored and labeled in accordance with currently accepted professional principles and manufacturers' recommendations and under proper temperature in 4 of 6 medication carts and failed to ensure medications were stored in locked compartments to permit only authorized personnel to have access.
- 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, interviews and record review, the facility failed to ensure cleaning of equipment per policy guidelines to maintain sanitary standards of equipment.
- 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 record review and interview, the facility failed to formulate advance directives for 1 of 3 residents, Resident #110, reviewed for advance directives.
- 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 of a resident change of condition for 1 of 3 residents, Resident #320, reviewed for insulin administration and monitoring.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to accurately document the discharge status of 1 of 3 residents, Resident #118, sampled for discharge status review.
- 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, interview, and record review, the facility failed to ensure the implementation of the comprehensive person-centered care plan for 2 of 7 residents, Residents #319 and #57, sampled for care plans.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide a therapeutic diet intervention as recommended by the Occupational Therapist and ordered by the physician for 1 resident, Resident #57, of 5 residents reviewed for nutrition.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection during medication administration and resident care for 1 of 2 residents, Resident #34 sampled for gastric tubes.
Fire safety inspections
14 fire safety citations on file: 8 on April 2, 2026, 1 on October 24, 2024, 5 on June 23, 2023.
Every fire safety citation14 citations
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Provide a means of sharing information on occupancy/needs.
E 34 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 23, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 23, 2023 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 23, 2023 · Corrected (the home has a date of correction)
- D
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 · June 23, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 23, 2023 · Corrected (the home has a date of correction)