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 10 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
4E
0F
Potential for minimal harm
0A
0B
0C
February 9, 2026Complaint inspection · 3 citations
- 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 clinical record review, policy review, family, and staff interviews, the facility failed to provide timely physician and family notifications for 1 of 4 residents (Residents #1) who experienced a change in condition or treatment. The facility reported a census of 39 residents.
- 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 clinical record review, staff interviews, and policy review, the facility failed to personalize 1 of 4 residents' Care Plan (Resident #1) by failing to include their use of diuretic medication therapy. The facility reported a census of 39 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, policy review, family, and staff interviews, the facility failed to provide assessments and interventions for 1 of 4 residents (#1). The facility reported a census of 39 residents.
October 16, 2025Complaint 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 clinical record review, facility document review, staff interview, and policy review, the facility failed to provide adequate nursing supervision to prevent a resident from exiting the facility into a patio area without staff's knowledge for 1 of 4 residents reviewed. The facility reported a census of 39.
June 19, 2025Standard inspection · 0 citations
April 16, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, family and staff interviews, personnel file review and policy review, the facility failed to provide timely assessment and interventions for 1 of 4 residents who experienced a change in condition (Resident #1). The facility reported a census of 40 residents.
October 17, 2024Complaint inspection · 3 citations
- 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 observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 40 residents.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 40 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, clinical record review, staff interview and resident interview, the facility failed to follow physician orders for dressing changes for 1 of 3 resident's (#3) reviewed. The facility reported a census of 40 residents. Findings Include: On 10/16/24 at 9:26 am, a dressing was observed on Resident #3's right shoulder. On 10/17/24 @ 9:45 am, Resident #3 stated her right shoulder dressing was not changed on 10/16/24. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of cancer, depression, right artificial shoulder joint, morbid obesity, and osteoarthritis. It indicated the resident required moderate to maximum assistance with all aspects of Activities of Daily Living (ADLs). [...]
July 15, 2024Standard inspection · 2 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, menu review, and staff interview, the facility failed to serve the appropriate portions for 5 residents who received mashed potatoes for lunch. The facility reported a census of 35 residents.
- 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, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food and not wearing beard covering while in the food service area. The facility reported a census of 35 residents.
November 30, 2023Standard inspection · 0 citations
Fire safety inspections
20 fire safety citations on file: 2 on June 19, 2025, 7 on July 15, 2024, 11 on November 30, 2023.
Every fire safety citation20 citations
- F
Provide properly protected cooking facilities.
K 324 · June 19, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 19, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · July 15, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · July 15, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 15, 2024 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · July 15, 2024 · 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 · July 15, 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 · July 15, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 15, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 30, 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 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 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 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 30, 2023 · 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
Have restrictions on the use of portable space heaters.
K 781 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 30, 2023 · Corrected (the home has a date of correction)