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
7D
6E
3F
Potential for minimal harm
0A
0B
0C
May 21, 2026Standard inspection, Complaint inspection · 7 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This has the potential to affect all 75 residents residing in the facility.
- F
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, the facility failed to properly store, label, and discard expired medication. This has the potential to affect all 75 residents residing in the facility.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to answer call lights in a timely manner for 5 out of 18 residents (R85, R54, R83, R79, R56) in a sample of 39; reviewed for Residents Rights.
- 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 implement an individualized transfer plan, initiate and implement appropriate interventions for 4 of 8 residents (R20, R9, R17 and R39) reviewed for accidents in the sample of 39.
- E
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 perform complete incontinent care for 4 of 5 (R2, R45, R65, R70) residents reviewed for toileting in a sample of 39.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene, change gloves, follow enhanced barrier precautions, ensure adaptive devices were in clean condition that promoted infection control standards of practice for 4 of 4 (R2, R8, R12, R42, R65, R68) reviewed for infection control in a sample of 39.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in Activities of Daily Living (ADLs), including a resident's mobility or walking, does not diminish for 1 of 1 resident (R65) reviewed for maintaining resident's ADLs in the sample of 39.
September 18, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview the facility failed to initiate a physician ordered antibiotic timely for 1 of 1 resident (R2) reviewed for Urinary Tract Infection (UTI) in the sample of 4.
- 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 provide complete incontinent and peri care to 3 of 3 residents (R1, R2, and R3) reviewed for incontinent care in the sample of 4.
April 17, 2025Standard inspection · 6 citations
- F
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, the facility failed to ensure a multi dose vial with a shelf life of 30 days was dated to indicate when it was opened and failed to ensure a bottle of controlled substance medication was labeled the residents name and physician's order. This failure has the potential to affect all 63 residents residing in the Facility.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide substitute food choices for 5 of 24 residents (R16, R28, R30, R49, R63) reviewed for meals.
- E
Provide and implement an infection prevention and control program.
Inspectors wrote4. R55's admission Record, dated 4/16/25, documents R55 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction with Hemiplegia and Hemiparesis, Dysphagia, Emphysema, Asthma, Congestive Heart Failure, Major Depressive Disorder, Generalized Anxiety Disorder, Malignant of Neoplasm of Sigmoid Colon, Gastrointestinal Hemorrhage, and Diverticulitis. On 4/15/25 at 1:05 PM, R55 used call light to let staff know he had to use restroom. V4, CNA, assisted R55 to the toilet to have bowel movement (BM). When finished, V4 wiped R55's buttocks and anal area with a wet washcloth sprayed with peri-wash, then dried R55. Using the same soiled gloves, V4 then pulled R55's incontinence brief and pants up, adjusted R55's shirt, and assisted R55 back to his wheelchair, then removed her soiled gloves. 5. [...]
- 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 provide timely and complete incontinent care for three of seven residents (R31, R38, R216) reviewed for incontinence care in the sample of 49. The Findings Include: 1. R38's admission Record, dated 4/16/25, documents R38 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease-stage 3, Hypertension, Descending Thoracic Aorta Aneurysm, Cerebral Infarction without residual deficits. R38's Care Plan, dated 3/20/25, documents R38 has a Self-Care Deficit as Evidenced by: Needs assistance with ADLs (activities of daily living). Interventions: Toilet Use - One-person physical assist required. It continues R38 has a Potential for impaired skin integrity related to: falls, impaired mobility, occasional incontinence. Interventions: Provide peri-care as needed. [...]
- 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 interview, observation, and record review, the facility failed to check placement of a J-tube (Jejunostomy) and label enteral feeding for 1 of 1 resident (R50) reviewed for tube feeding in the sample of 49.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to justify the use of an antibiotic and utilize infection surveillance when considering initiation of an antibiotic for 2 of 4 (R32, R41) residents reviewed for antibiotic stewardship in the sample of 49.
May 7, 2024Standard inspection · 1 citation
- 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 record review the facility failed to ensure resident's advance directives and physician's orders reflected resident's wishes for 2 of 3 residents (R41 and R58) reviewed for advance directives in a sample of 25.
Fire safety inspections
3 fire safety citations on file: 2 on May 21, 2026, 1 on April 17, 2025.
Every fire safety citation3 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 21, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 21, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 17, 2025 · Corrected (the home has a date of correction)