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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
2E
0F
Potential for minimal harm
0A
1B
0C
January 23, 2026Standard inspection · 9 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure that grievances from Resident Council were acted upon and demonstrate their response to the group for 3 of 4 months of meeting minutes reviewed.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that residents were assessed to self-administer medications for 2 of 5 residents reviewed for choices in a final sample of 19 residents. (Resident identifiers are #21 and #70.)
- D
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Inspectors wroteBased on interview and record review the facility failed to conduct a criminal background check on staff prior to providing direct resident care for 1 of 6 staff records reviewed. (Staff identifier is Q.)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that medications were given according to professional standards and manufacturer's instructions for 1 of 30 medication administration observations (Resident #72) and according to physician orders for 2 residents in a final sample of 19 residents. (Resident identifiers are #39 and #55.)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide appropriate adaptive equipment to maintain independent wheelchair mobility for 1 of 1 residents reviewed for physical restraints in a final sample of 19 residents (Resident identifier is #4).
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide services to maintain or improve his/her ability for mobility in 1 of 2 residents reviewed for rehabilitation and restorative services in a final sample of 19 residents (Resident Identifier is #78).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that staff use appropriate equipment for resident transfers for 1 of 3 residents reviewed for abuse in a final sample of 19 residents. (Resident identifier is #21.)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure infection control techniques were followed for 1 of 2 Capillary Blood Glucose (CBG) tests observed and 7 of 30 medications observed. (Resident identifier is #88.)
- D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to develop, implement, and maintain an effective training program for all staff for 1 of 5 staff records reviewed.
November 15, 2024Standard inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for the use of appropriate Personal Protective Equipment (PPE) to prevent the spread of infection for 4 of 8 residents on Transmission Based Precautions (TBP) for COVID-19 infection (Resident identifiers are #2, #7, #73, and #84).
December 21, 2023Standard inspection, Complaint inspection · 6 citations
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to take appropriate action after an investigation for 1 of 2 residents reviewed for abuse in a final sample of 22 residents (Resident Identifier is #22).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to update resident care plans with new or revised interventions for 1 of 2 residents reviewed for pressure ulcers and 1 of 5 residents reviewed for nutrition in a final sample of 22 residents (Resident Identifiers are #22 and #250).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow professional standards for assessing a resident for injury (diagnosed with a fractured right pelvic and sacrum) after a fall for 1 of 2 residents reviewed for falls and for not following physician's orders when providing wound care for 1 of 2 residents reviewed for pressure ulcers in a final sample of 22 residents (Resident Identifier is #22).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that facility sponsored group and individualized activities were provided to support residents for 1 of 1 resident reviewed for activities in a final sample of 22 residents (Resident Identifier is #22).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement measures to prevent the development of pressure ulcers in 1 of 2 residents reviewed for pressure ulcers in a final sample of 22 residents (Resident Identifier is #22).
- B
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, it was determined that the facility failed to ensure all drugs are stored in locked compartments with only authorized personnel having access for 1 of 2 medication rooms observed.
Fire safety inspections
12 fire safety citations on file: 7 on January 23, 2026, 2 on November 15, 2024, 3 on December 21, 2023.
Every fire safety citation12 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
K 913 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 23, 2026 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 23, 2026 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 15, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · December 21, 2023 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 21, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 21, 2023 · Corrected (the home has a date of correction)