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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
5D
2E
0F
Potential for minimal harm
0A
0B
1C
October 6, 2025Standard inspection, Complaint inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, hospital record review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program/fall interventions to decrease Resident #2's risk of falls including falls with injury. This affected one resident (#2) of one resident reviewed for falls. The facility census was 82. Actual Harm occurred on 12/09/24 when Resident #2, who was at risk for falls and had a history of falls, sustained a left hip fracture without evidence the facility had implemented individualized and effective interventions to prevent the fall with fracture. The resident had sustained falls on 11/29/24 and 12/08/24 with the only intervention listed post fall was to remind the resident to call for assistance. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on resident record review, staff interviews, review of Self-Reported Incidents (SRIs), and review of facility concern logs, a soft file investigation and facility policy review, the facility failed to ensure Residents #33 and #48 were free from verbal and physical abuse. This affected two residents (#33 and #48) of two residents reviewed for abuse. The facility census was 82.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on resident record review, staff interviews, review of Self-Reported Incidents (SRIs), review of facility soft file investigation, and facility policy review, the facility failed to report an incident of alleged abuse to the State Agency. This affected one (Resident #48) of two residents reviewed for abuse. The facility census was 82.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observations, staff interviews, and facility policy review, the facility failed to provide accommodation for a dependent resident's needs. This affected one (Resident #38) of three residents reviewed for nutrition. The facility census was 82.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure medications were given according to physician's orders, creating a medication error rate of 16.0 percent (%). This affected two residents (#29 and #32) of three residents observed for medication administration. The facility census was 82.
December 21, 2023Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, review of the Self-Reported Incident (SRI) and interviews, the facility did not ensure all residents were protected from misappropriation of resident funds by staff. This affected one resident of four residents reviewed for resident rights. The facility census was 74.
August 3, 2023Standard inspection · 0 citations
March 12, 2020Standard inspection · 3 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, record review and interview the facility failed to ensure a variety of foods were offered for Resident #51 and Resident #85 and failed to ensure Resident #2, Resident #65 and Resident #80, who were ordered a pureed diet received the proper serving size of soup. This affected two residents (#51 and #85) of four residents reviewed for food concerns based on the menu and three residents (#2, #65 and #80) of three residents reviewed for pureed diets.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure a sanitary food preparation area was maintained during tray/serving line of meals to prevent potential contamination and/or food borne illness. This had the potential to affect 44 residents (#1, #2, #4, #5, #7, #9, #12, #13, #14, #18, #20, #22, #24, #27, #28, #29, #31, #35, #37, #48, #49, #51, #52, #58, #61, #64, #65, #66, #68, #73, #74, #77, #79, #80, #81, #84, #88, #90, #91, #93, #293, #294, #295 and #296) of 45 residents who take foods by mouth, reside on the second floor and receive their meals from the pantry.
- C
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interview the facility failed to ensure proper bed hold notices were provided as required upon resident transfers to the hospital. This affected two residents (#3 and #66) and had the potential to affect all 87 residents residing in the facility.
Fire safety inspections
10 fire safety citations on file: 5 on October 6, 2025, 5 on August 3, 2023.
Every fire safety citation10 citations
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · October 6, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 6, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · October 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 · October 6, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 6, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 3, 2023 · Corrected (the home has a date of correction)