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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
8E
2F
Potential for minimal harm
0A
0B
0C
June 3, 2026Standard inspection · 3 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 facility policy review, the facility failed to ensure food items stored in the residents' nourishment refrigerator were labeled, dated, and discarded after the expiration date. This deficient practice had the potential to affect all 88 residents who currently reside in the facility.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and document review, the facility failed to have an Infection Preventionist (IP) that possessed specialized training in infection prevention and control. This deficient practice had the potential to affect all 88 residents who currently reside in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff did not reuse a disinfectant wipe during medication administration for 2 (Resident #46 and Resident #62) of 7 residents observed for medication administration.
August 2, 2024Standard inspection · 5 citations
- E
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, record review, and interview, the facility failed to ensure residents were provided with a comfortable, homelike environment for two (#60 and #75) of six sampled residents who were reviewed for noise level/comfortable, homelike environment. The DON identified 76 residents who resided in the facility.
- E
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 physician's orders were documented properly for one (#49) of six residents whose physician's orders were reviewed for accuracy. The DON identified four residents who had tube feedings
- 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 and interview, the facility failed to ensure the kitchen was maintained in good repair. The administrator identified 73 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurate for one (#74) of six sampled residents whose assessments were reviewed for accuracy. The DON identified 76 residents who resided in the facility.
- 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 care plan behaviors for one (#74) of six sampled residents whose care plans were reviewed for accuracy. The DON identified 76 residents who resided in the facility.
June 23, 2023Standard inspection · 9 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for three (#32, 53, and #60) of 26 residents whose assessments were reviewed. The Residents Census and Conditions Of Residents form Documented 65 residents resided in the facility.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote2. Res #7 had diagnoses which included heart failure, COPD and lower back pain. A physician order, dated 06/10/22, documented the facility was to administer furosemide (a diuretic medication) one time a day for edema related to heart failure. A physician order, dated 08/13/22, documented the facility was to administer tramadol (an opioid medication used for pain) two times a day for pain related to lower back pain. A physician order, dated 02/19/23, documented the facility was to administer Norco (a pain medication) every eight hours as needed for pain. A quarterly assessment, dated 06/20/23, documented the resident was intact with cognition and required supervision to limited assistance with most ADLs. The assessment documented the resident used diuretic and opioid medications. Res #7's care plan was reviewed and did not observe a care plan for diuretic or opioid use. [...]
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review, it was determined the facility failed to conduct annual CNA competencies for three of five employee records reviewed. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the blood pressure and heart rate were monitored before holding a medication as ordered by the physician for two (#32 and #48) of five sampled residents whose medications were reviewed for unnecessary medications. The Residents Census and Conditions Of Residents form Documented 65 residents resided in the facility.
- 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 and interview, the facility failed to ensure the kitchen was maintained in good repair. The Residents Census and Conditions Of Residents form documented 65 residents resided in the facility.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to conduct a significant change assessment after the resident was admitted to hospice services for one (#116) of 26 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 65 residents who resided in the facility.
- D
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 develop and implement interventions to prevent falls for one (#168) of five residents sampled for accident hazards and falls. Res #168 was admitted to the facility on [DATE] for skilled nursing and therapy related to a fall at home which had resulted in a right hip fracture. The resident had a fall in the facility on 03/14/22 which resulted in a second broken right hip that required another surgery. No interventions were in place to prevent falls from the resident's admit until the fall on 03/14/22. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure the physician and/or NP responded in the proper time frame to a pharmacist MRR for two (#7 and #32) of five sampled for unnecessary medications and failed to ensure the MRR policy documented the required components. The Residents Census and Conditions Of Residents form Documented 54 receiving psychoactive medications resided in the facility.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure ordered medications documented an appropriate diagnosis for one (#32) of five residents reviewed for unnecessary medications. The Residents Census and Conditions Of Residents form Documented 54 receiving psychoactive medications resided in the facility.
Fire safety inspections
6 fire safety citations on file: 3 on June 3, 2026, 3 on June 23, 2023.
Every fire safety citation6 citations
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 3, 2026 · 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 · June 3, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 3, 2026 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · June 23, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 23, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 23, 2023 · Corrected (the home has a date of correction)