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
12D
1E
1F
Potential for minimal harm
0A
0B
0C
August 21, 2025Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to ensure temperatures for the kitchen beverage cooler and high temperature dishwasher were maintained at the recommended temperature to minimize growth of microorganisms.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to properly store a nebulizer mask (a drug delivery device used to administer medication in the form of a mist which is inhaled into the lungs) for 2 residents (Resident #94 and Resident #115) of 5 sampled residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure assessment for contraindications to COVID-19 vaccines were documented in the medical record for 1 resident (Resident #1) of 5 residents reviewed for immunizations.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews the facility failed to ensure enhanced barrier precautions were followed for 1 resident (Resident #104) of 16 residents reviewed for enhanced barrier precautions (EBP).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to assess 2 residents (Residents #1 and #10) for medical contraindications prior to providing the Influenza vaccine of 5 residents reviewed for immunizations.
June 5, 2024Standard inspection · 5 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observations, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Resident #25 and #11) of 18 residents reviewed for MDS assessments.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) after new mental health diagnoses were identified for 1 resident (Resident #44) of 12 residents reviewed for PASARR.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was accurate upon admission for 1 resident (Resident #11) of 12 residents reviewed for PASARR.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to implement a comprehensive care plan to reflect a Post Traumatic Stress Disorder (PTSD) diagnosis for 1 (Resident #24) of 18 residents reviewed for care plans.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, observations, and interview the facility failed to secure medications for 1 resident (Resident #7) of 18 residents screened for accidents and hazards.
July 20, 2022Standard inspection · 4 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy review, medical record review, interview, and observation, the facility failed to follow a physician's order for fluid restrictions for 2 residents (#16 and #38) of 3 residents reviewed for fluid restrictions and failed to obtain weights as ordered for 1 resident (#16) of 3 residents reviewed for weights.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to develop a care plan for 2 residents (#10 and #27) of 18 residents reviewed for care plans.
- 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 facility policy review, medical record review, observations, and interviews, the facility failed to follow a physician's order in obtaining a follow up urology (branch of medicine concerned with the function of the urinary system) appointment to assess an indwelling urinary catheter (a tube inserted into the bladder that remains in place to provide continuous urinary drainage) for 1 resident (#10) of 4 residents reviewed for urinary catheters.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to maintain a completed Physician Order for Scope of Treatment (POST) form in the medical record for 1 resident (#10), and failed to obtain a physician's order for an accurate code status for 1 resident (#30) of 18 residents reviewed for Advance Directives.
Fire safety inspections
5 fire safety citations on file: 2 on June 5, 2024, 3 on July 20, 2022.
Every fire safety citation5 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 5, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · July 20, 2022 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · July 20, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 20, 2022 · Corrected (the home has a date of correction)