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
16D
0E
0F
Potential for minimal harm
0A
0B
0C
January 21, 2026Complaint 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 reviews and staff interviews, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #3) for falls. The facility reported a census of 114 residents.
September 10, 2025Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, facility investigation, facility policy/procedures, and staff interviews the facility failed to provide a supportive and safe environment for 1 of 3 residents reviewed (Resident #1). On 8/3/25, the facility staff learned of a Certified Nurse Aide (CNA) being accused of taking a photograph of Resident #1. After learning of this allegation, the facility staff allowed the CNA to work with Resident #1 and all other residents for an entire 8 hour shift. The facility identified a census of 122 residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, facility policy/procedure, employee time card, and staff interviews, the facility failed to protect vulnerable residents from an alleged abuser. On 8/3/25 at 1:30 p.m., facility staff were aware of a photograph that was taken of 1 of 3 residents reviewed (Resident #1). Facility staff allowed the alleged abuser to work their entire shift on 8/3/25 and allowed the alledged abuser to work with Resident #1 and all other vulnerable residents and failed to notify the facility administration of the allegation. The facility identifed a census of 122 residents.
July 3, 2025Standard inspection · 3 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wrote2. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of hypertension (high blood pressure), heart failure (heart does not pump blood well), coronary artery disease, and chronic kidney disease. Review of Census and Progress Notes revealed Resident #8 was admitted to the hospital for congestive heart failure from 3/5/25 to 3/6/25 and 3/10/25 to 3/17/25. The facility form titled Notice of Transfer Form to Long Term Care Ombudsman used to track discharges and notify the Ombudsman of a discharge revealed Resident #3 was not listed on the forms for March or April 2025. [...]
- 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 clinical record review, staff interviews and policy review the facility failed to change indwelling catheter per physician orders for 1 of 1 resident reviewed (Resident #85) for catheter care. The facility reported a census of 117 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, staff interviews, and resident interview, the facility failed to change oxygen tubing and water humidifier for 1 of 1 resident reviewed (Resident #3) for respiratory services. The facility reported a census of 117 residents. Findings Include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of hypertension (high blood pressure), heart failure (heart does not pump blood well), coronary artery disease, and chronic kidney disease. The MDS documented Resident #3 received oxygen and a non-invasive mechanical ventilator (CPAP) while a resident within the last 14 days. [...]
December 31, 2024Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, staff interview and policy review, the facility failed to report an allegation of abuse timely after the allegation was made for 1 of 1 residents reviewed for alleged abuse (Resident #1). The facility reported a census of 116 residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, staff interview and policy review, the facility failed to separate an alleged abuser from a resident for 1 of 1 residents reviewed for alleged abuse (Resident #1). The facility reported a census of 116 residents.
November 21, 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 record review and staff interview, the facility failed to report an allegation of abuse immediately, but not later than 2 hours after the allegation was made for 1 resident (Resident #1). The facility reported a census of 118 residents.
August 8, 2024Standard inspection, Complaint inspection · 3 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to use safety principles while transporting 2 residents in their wheelchairs (Residents #56 and #71). An observation revealed both pushed from the dining area to their rooms without the staff applying foot pedals on to their wheelchairs. Each resident had to hold their feet off the floor during transport. The facility reported a census of 116.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to check proper gastrostomy tube (a tube inserted through a hole in the abdomen into the stomach to administer nutrition and medications) placement prior to administering medications to 1 of 1 resident observed (Resident #49). The facility reported a census of 116 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to complete post dialysis assessments for 1 of 1 resident reviewed for receiving dialysis (Resident #113). The facility reported a census of 116 residents.
January 25, 2024Standard inspection, Complaint inspection · 4 citations
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and staff interview, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment no less than 3 months after the last assessment for 2 of 2 residents reviewed (Resident #40 and #105). The facility reported a census of 116 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and staff interview the facility failed to accurately complete the Residents' Minimum Data Set (MDS) assessments by not coding for an unhealed pressure ulcer (soft tissue injuries from prolonged pressure to areas of the body) and use of physical restraints for 2 of 2 residents reviewed. (Residents #49 and #76). The facility reported a census of 116 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 and staff interviews, the facility failed to follow a comprehensive Care Plan for 1 of 1 residents reviewed for transfers (Resident #104). The facility reported a census of 116 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to follow professional standards in regards to physician follow-up with reassessing as needed (PRN) psychotropic medication for 1 of 4 residents reviewed (Resident #26). The facility reported a census of 116 residents.
Fire safety inspections
10 fire safety citations on file: 3 on July 3, 2025, 3 on August 8, 2024, 4 on January 25, 2024.
Every fire safety citation10 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 3, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · July 3, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 3, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 8, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 8, 2024 · Waiver
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 25, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 25, 2024 · 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 · January 25, 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 25, 2024 · Corrected (the home has a date of correction)