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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
3D
2E
2F
Potential for minimal harm
0A
0B
0C
July 30, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and implement resident-specific fall prevention interventions to prevent accidents/injuries for two (R48 and R92) of six residents reviewed for accidents and supervision in the sample of 106. These failures resulted in actual harm to R92 after a fall forward from the wheelchair sustaining a laceration requiring sutures
August 1, 2025Complaint inspection · 1 citation
- 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 monitor nephrostomy output for one of one resident (R18) reviewed for nephrostomy tubes, failed to wear appropriate Personal Protective Equipment and cleanse the urinary catheter during urinary catheter cares for one of six residents (R40), reviewed for urinary catheter care in a sample of 96.
August 16, 2024Standard inspection · 2 citations
- 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 serve all residents at a table at the same time for five (R9, R27, R32, R36 and R45) of 26 residents reviewed for residents' rights in a sample of 28.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to ensure proper disposal of Personal Protective Equipment for four residents (R6, R11, R51, R150) of 28 residents reviewed for Infection Control in a sample of 28.
June 15, 2023Standard inspection · 3 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, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 79 residents residing in the facility.
- 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 record review, the facility failed to provide incontinent care for one of three residents (R16) reviewed for bowel and bladder incontinence in the sample of 30.
- 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 record review, the facility failed to document behaviors to warrant the initiation of an antipsychotic medication for one of one resident (R16) reviewed for antipsychotics in the sample of 30.
April 28, 2022Standard inspection · 1 citation
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to date opened food, date food received or thawed, date thawed health shakes, clean the convection oven, ensure a covering for a food cart to keep food warm, and failed to wear a hair net in the kitchen. These failures have the potential to affect all 61 residents except R32 who is NPO (nothing by mouth).
Fire safety inspections
14 fire safety citations on file: 5 on August 16, 2024, 6 on June 15, 2023, 3 on April 28, 2022.
Every fire safety citation14 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 16, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 16, 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 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 16, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 15, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 15, 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 · June 15, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · June 15, 2023 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · June 15, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 15, 2023 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · April 28, 2022 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · April 28, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 28, 2022 · Corrected (the home has a date of correction)