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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
0E
1F
Potential for minimal harm
0A
0B
0C
December 3, 2025Standard inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review, the facility failed to consistently follow provider's orders for one of five residents (R1) investigated for unnecessary medication. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had diagnoses which included: heart failure, respiratory failure, anxiety and depression. R1's MDS identified R1 received diuretics (medication to help remove excess fluids). R1's care plan revised 12/3/25, identified R1 was at risk for cardiac complications related to history of respiratory failure and diagnoses of congestive heart failure (CHF), atrial fibrillation (A-Fib, irregular heart and often rapid heart rhythm) and hypertension (HTN, high blood pressure). [...]
July 11, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate hand hygiene was performed during personal cares for 1 of 1 residents (R3) reviewed for hand hygiene.
October 23, 2024Standard inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and document review, the facility failed to maintain the water and ice machines in a sanitary manner to prevent potential contamination for 69 residents who currently received water and ice from the ice machines. In addition, the facility failed to maintain the coffee machine on the Meadow [NAME] unit in a sanitary manner to prevent potential contamination for the residents who currently used the coffee machine.
- 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 interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the resident's medical record to ensure residents wishes would be implemented correctly in an emergency for 3 of 25 residents (R10, R60, R68) reviewed for advanced directives. Findings Include: R10 R10's admission Minimum Data Set (MDS) dated [DATE], identified R10 was cognitively intact and had diagnoses which included: heart failure, diabetes mellitus, and respiratory failure. Review of R10's electronic medical record (EMR) identified the following: -R10's dashboard Profile (banner viewed on computer screen) identified Advance Directive: do not resuscitate (DNR). -R10's Physician Order Report identified Advance Directive: Full Code, order date [DATE]. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and document review, the facility failed to appropriately implement identified pressure relieving interventions to promote healing for 1 of 3 resident (R1) reviewed with current, recurring, stage three (3) pressure ulcer on R1's left heel. Stage 3 pressure ulcer; full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Slough; non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.
- 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 document review, the facility failed to identify the root cause of falls, implement appropriate interventions and follow care planned interventions for 2 of 3 residents (R 29, R127) who had multiple falls in the facility.
December 13, 2023Standard inspection, Complaint inspection · 4 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications for 2 of 7 residents (R21, R46) reviewed for medication administration.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 3 residents( R14) reviewed for activities of daily living (ADL)'s.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and document review, the facility failed to implement hand hygiene for 3 of 7 residents (R46, R48, and R16) observed during medication administration.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 resident (R51, R56) was offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations.
November 22, 2023Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteELOPEMENT Based on interview and document review, the facility failed to ensure supervision for 1 of 3 residents (R1) reviewed for accidents. This failure resulted in an immediate jeopardy (IJ) when R1 eloped from the facility and was not discovered missing for two hours, despite being on hourly checks. The IJ began on 11/7/23, when R1 eloped from the facility and was out of the facility for four hours and found by law enforcement approximately 2.4 miles away from the facility. The facility administrator and director of nursing (DON) were notified of the IJ at 5:30 p.m. on 11/22/23. The facility implemented corrective action by 11/9/23, prior to the start of the survey and was issued as past non-compliance. [...]
Fire safety inspections
11 fire safety citations on file: 7 on December 3, 2025, 2 on October 23, 2024, 2 on December 13, 2023.
Every fire safety citation11 citations
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · December 3, 2025 · 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 · December 3, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · December 3, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 3, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 3, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 3, 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 23, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 13, 2023 · 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 · December 13, 2023 · Corrected (the home has a date of correction)