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 15 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
1E
1F
Potential for minimal harm
0A
0B
0C
December 4, 2025Standard inspection · 0 citations
October 2, 2025Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to ensure dignity was maintained for 1 of 3 residents (R2) reviewed for dignity related to dressing. Findings Include: R2's admission minimum data set (MDS) dated [DATE], indicated R2 was admitted on [DATE], was able to communicate clearly and understand others, moderate to mild cognitive impairment category, and had the following diagnoses: anxiety, mood disturbance, and dementia. R2's care plan last revised 8/29/25, indicated R2 required an assist of one for dressing related to activity intolerance, Dementia, and impaired balance. The care plan also indicated R2 had enhanced psychosocial well-being related to individualized daily routine and honoring personal preference. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and document review failed to provide repositioning and toileting/incontinence cares for 1 of 3 residents (R2) reviewed for activities of daily living (ADL) and who were dependent on staff for ADL's. Findings Include: R2's admission minimum data set (MDS) dated [DATE], indicated R2 was admitted on [DATE], was able to communicate clearly and understand others, was moderate to mild cognitive impairment category, and had the following diagnoses: anxiety, mood disturbance, and dementia. R2's Braden Scale for Predicting Pressure Sore Risk dated 9/23/25 had a score of 14 indicating R2 is a moderate risk for skin breakdown. The intervention guide included frequent turning with a planned schedule and managing moisture. R2's care plan last revised 8/29/25, indicated R2 has bowel and blader incontinence related to Alzheimer's Disease. [...]
February 14, 2025Complaint inspection · 1 citation
- 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 observation, interview and document review, the facility failed to ensure acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or recorded to ensure efficacy of as-needed (PRN) psychotropic medication for 2 of 3 residents (R1, R3) reviewed for unnecessary medications.
October 17, 2024Standard inspection · 6 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and document review, the facility failed to initiate appropriate transmission based precautions according to The Centers for Disease Control (CDC) for 2 of 3 residents (R11, R224) reviewed for transmission based precautions, failed to track and trend potential/actual infections for 6 of 6 residents (R11, R35, R36, R24, R1, R224) identified to have potential/actual infections; and failed to conduct COVID-19 testing per CDC guidelines for 5 of 5 residents (R11, R35, R36, R24, R15) who were identified to have COVID-19 signs and symptoms. This had the potential to affect all 68 residents residing in the facility.
- D
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 document review, the facility failed to ensure a urinary catheter bag was placed in a privacy bag to maintain dignity for 1 of 3 residents (R25) reviewed for dignity.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review, the facility failed ensure clinical monitoring was completed and documented for 2 of 3 residents (R37, R39) reviewed with recent COVID-19 infections.
- 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 interview and document review, the facility failed to ensure an appropriate provider's order and rational for use were obtained for an indwelling urinary catheter for 1 of 3 residents (R30) who were reviewed for catheter care.
- 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 observation, interview and document review, the facility failed to ensure staff provided care according to standards of practice and per physician orders for gastrostomy tube feeding for 1 of 1 resident (R15) reviewed for tube feedings.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a discontinued presciption topical antifungal medication was detroyed and not administered; and failed to ensure only authorizied staff administered prescribed adminstered prescribed creams for 1 of 1 resident (R15) observed to have nursing assistants apply prescribtion creams during cares without an order.
June 12, 2024Complaint inspection · 3 citations
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and document review, the facility failed to create an individualized discharge care plan, to develop interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition from the facility to the post-discharge setting, for 1 of 3 residents (R3) reviewed.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and document review the facility failed to ensure physician treatment orders were followed for 1 of 3 (R2) residents reviewed for pressure ulcers.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and document review the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed, who was cognitively impaired and arrived at an outpatient appointment unaccompanied and was noted to be disorientated and exhibiting aggressive behaviors.
January 4, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and document review, the facility failed to follow physician orders for a non-pressure related wound, to promote healing, for 1 of 3 residents (R1) who were reviewed.
December 20, 2023Standard inspection · 2 citations
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and document review, the facility failed to provide the most recent Centers for Disease and Prevention (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R32, R36, R49) reviewed for pneumococcal immunizations.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and document review, the facility failed to use the ordered wound care to promote wound healing for 1 of 1 resident (R37) reviewed for pressure ulcers.
Fire safety inspections
8 fire safety citations on file: 2 on December 4, 2025, 3 on October 17, 2024, 3 on December 20, 2023.
Every fire safety citation8 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 4, 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 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 17, 2024 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 17, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · October 17, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 20, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 20, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · December 20, 2023 · Corrected (the home has a date of correction)