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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
3E
0F
Potential for minimal harm
0A
0B
0C
June 29, 2026Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clincal record review, observations, and staff and resident interviews it was determined the facitliy failed to provided services that meet professional standards for one of one residents reviewed. (Resdient 1)
December 11, 2025Standard inspection · 6 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide hydration for fifteen of thirty-two rooms on the 1st floor dementia care unit. Observations made of resident rooms on December 8, 2025, December 9, 2025, and December 10, 2025, revealed rooms 100 through 115 had no cups of fresh water for resident's hydration or the cups were dated between November 14, 2025, and December 1, 2025. Rooms 116 through 132 were observed to have currently dated cups with fresh water. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of rooms [ROOM NUMBERS] revealed cups of water dated November 14, 2025. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of room [ROOM NUMBER] revealed a cup of water dated December 1, 2025. All remaining rooms between 100 and 115 had no water cups. [...]
- E
Ensure resident rooms meet each resident's needs.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide privacy curtains for three of thirty-two resident rooms and failed to provide clean privacy curtains for eighteen of thirty-two resident rooms located on the 1st floor dementia care unit. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 3 rooms with missing privacy curtains. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 18 rooms with privacy curtains that were soiled or had brown stains on them. [...]
- 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 upon clinical record review, it was determined that the facility failed to ensure appropriate advance directives regarding code status were in place for one of 33 residents reviewed. (Resident 114)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of 33 residents reviewed (Resident 29)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased upon clinical record review, it was determined that the facility failed to ensure appropriate monitoring for side effects and effectiveness were completed for the use of an anti-depressant medication for one of 33 records reviewed (Resident 35).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to provide an assistive device for one of seven residents investigated, (Resident 7). Review of Resident 7's physician orders revealed an order for regular diet, regular texture, thin consistency [NAME] Cup (a spill-proof drinking cup with a secure lid and J-shaped handle) built up fork and spoon dated May 21, 2025. Review of Resident 7's care plan revealed a care plan for nutritional problem or potential nutritional problem related to need for assist with meals, intellectual disability, and weight stable. Review of Resident 7's face sheet revealed medical diagnoses that include Encephalopathy (a group of conditions that cause brain dysfunction). [...]
April 30, 2025Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for two of four residents reviewed (Residents 1 and 3).
October 9, 2024Standard inspection · 3 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on policy review, observation, and staff interview, it was determined that the facility failed to properly store food in the dry storage located next to the main kitchen.
- 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 review of facility policy, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consisted, adequate catheter care was provided to one of seven residents reviewed for catheters (Resident 94).
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to report results for laboratory studies to the ordering physician timely for one of 40 residents reviewed. (Resident 22) Findings Include: Review of Resident 22's Physician orders revealed an order dated September 11, 2024 for a UA C+S (test of urine to determine if there is a Urinary Tract Infection). Review of Resident 22's Laboratory report for the UA C+S revealed the report was final and was reported on September 15, 2024. Review of Resident 22's Progress Notes revealed a nursing entry on September 18, 2024 stating the results were posted and reported to the physician who ordered antibiotics to treat the urinary tract infection. Interview with the DON on October 9, 2024 at 11:30 a.m. [...]
November 30, 2023Standard inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record and facility documentation review and resident/staff interview, it was determined that the facility failed to timely treat a burn and failed to follow a physician medication parameter for two of 33 residents reviewed (Residents 32 and 58).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical records facility documentation review and staff interview, it was determined that the facility failed to timely assess a resident's skin impairment and inform the physician of a newly found skin impairment for one of six residents reviewed (Resident 58).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review, it was determined that the facility failed to ensure one of 33 residents reviewed was free of unnecessary medications (Resident 137).
Fire safety inspections
16 fire safety citations on file: 2 on December 11, 2025, 7 on October 9, 2024, 7 on November 30, 2023.
Every fire safety citation16 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2025 · 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 · December 11, 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 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · October 9, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · October 9, 2024 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · November 30, 2023 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 30, 2023 · Corrected (the home has a date of correction)
- C
Have properly located and lighted "Exit" signs.
K 293 · November 30, 2023 · Corrected (the home has a date of correction)