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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
3E
1F
Potential for minimal harm
0A
0B
0C
April 15, 2026Standard inspection · 8 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, interview and record review the facility failed to ensure the menu was followed for the noon meal for the residents on pureed diets to 4 of 8 residents (R10, R59, R62 and R69) reviewed for dietary services in the sample of 18.
- 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 interview and record review the facility failed to notify a resident's power of attorney (POA) of a change in condition for 1 of 4 residents (R3) reviewed for change of condition in a sample of 18.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed anxiety medication had a stop date for one of 18 residents (R69) reviewed for psychotropics in the sample of 18.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review the facility failed to monitor a non pressure wound for one of 18 residents (R4) reviewed for quality of care in the sample of 18.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to clean a pressure injury in a manner to prevent cross contamination and failed to have pressure injury preventions in place for three of four residents (R4, R30, R69) reviewed for pressure injury in the sample of 18.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter tubing was kept off the floor for 1 of 4 residents (R37) reviewed for indwelling urinary catheters in the sample of 18.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident with a plate guard for 1 of 2 residents (R8) reviewed for assistive devices in the sample of 18.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions. This applies to 2 of 18 residents (R37 and R50) reviewed for infection control in the sample of 18.
February 4, 2026Complaint inspection · 1 citation
- 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 fall prevention interventions were in place for four of four residents (R1-R4) reviewed for safety/supervision in the sample of four.
May 30, 2025Complaint inspection · 1 citation
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician ordered referral to a specialist was initiated and facilitated for one resident (R1) of three residents reviewed for community medical appointments.
February 26, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the correct personal protective equipment (PPE) and failed to complete handwashing prior to leaving residents' rooms on contact isolation for norovirus while the facility is in outbreak status. This applies to 2 of 26 (R1, R2) residents reviewed for infection control.
February 6, 2025Standard inspection · 3 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide residents with a safe and comfortable home-like environment that enhanced each resident's overall quality of life by not maintaining an effective preventative maintenance plan due to observing wall in resident's room with areas of visibly scraped paint throughout room; chair railing not secured to the wall that exposed nails and caused drywall dust to accumulate on the floor; multiple bathroom doors with visible deep scrapes and holes to the middle and lower portions; and the heating baseboard cover plates were not firmly attached or were missing. This failure directly affected 14 residents (R1, R5, R6, R9, R14, R16, R25, R33, R49, R50, R59, R65, R69, and R75) within 13 total rooms in a sample size of 36.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to have interventions in place to prevent a pressure ulcer, failed to identify an area of pressure before becoming a stage 3 and failed to have a new pressure ulcer assessed by the wound care provider while in the facility. These failures resulted in R39's pressure ulcer worsening. This applies to two of four residents (R39, R27) reviewed for pressure in the sample of 36.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent resident received timely incontinence care and failed to ensure a resident with an indwelling catheter maintained the drainage bag below the level of the bladder for 2 of 4 residents (R21, R12) reviewed for bowel and bladder in the sample of 36.
November 6, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to follow their policies and procedures on reporting an allegation of abuse for 1 of 7 residents (R1) reviewed for abuse in the sample of 7.
January 30, 2024Complaint inspection · 2 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident's personal funds were refunded upon discharge. This applies to 1 of 4 residents (R1) reviewed for personal funds in the sample of 4.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to provide a resident's medications upon discharge. This applies to 1 of 3 residents (R1) reviewed for discharge in the sample of 4.
January 4, 2024Standard inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to have interventions in place to prevent a pressure injury for 1 of 4 residents (R57) reviewed for pressure injuries in the sample of 17.
- 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 record review, the facility failed to ensure quarterly smoking assessments were completed for 1 of 2 residents (R32) reviewed for smoking safety in the sample of 17.
October 31, 2023Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review the facility failed to perform testing for two weeks after a resident tested positive for Covid 19. This applies to all 73 residents residing at the facility.
Fire safety inspections
16 fire safety citations on file: 6 on April 15, 2026, 5 on February 6, 2025, 5 on January 4, 2024.
Every fire safety citation16 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 6, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 6, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 6, 2025 · 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 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 4, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 4, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 4, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 4, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 4, 2024 · Corrected (the home has a date of correction)