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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
2E
0F
Potential for minimal harm
0A
0B
1C
January 6, 2026Standard inspection · 5 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oral suctioning was completed and documented as ordered for 1 of 4 residents reviewed for respiratory care (Resident 4), medications were administered as ordered for 1 of 4 residents reviewed for accidents (Resident 1), wound assessments were completed and skin discolorations were monitored for 2 of 6 residents reviewed for non-pressure skin conditions. (Residents 24 and 67)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications, for 1 of 1 resident reviewed for self-administration of medication. (Resident 55)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to following physician's orders for oxygen administration for 1 of 4 residents reviewed for respiratory care. (Resident 67)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were given with adequate indication for use related to lack of non-pharmacological interventions prior to giving pain medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 93)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to staff not wearing personal protective equipment (PPE) correctly when entering an isolation room for 2 of 2 residents reviewed for COVID-19. (Residents 88 and 55) The facility also failed to ensure infection control practices and standards were maintained related to medication administration for 1 of 7 residents observed during the medication administration observation. (Resident 53)
November 1, 2024Standard inspection · 6 citations
- 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 observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed and in place for a resident with a history of MDROs (multi-drug resistant organisms) for 1 of 18 resident care plans reviewed. (Resident 71)
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plans were implemented and/or updated for 2 of 21 resident care plans reviewed. (Residents 21 and 14)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations and a skin lesion for 2 of 3 residents reviewed for non-pressure related skin conditions. (Residents 21 and 14)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure palm protectors and/or splints were in place as ordered for residents with contractures (a shortening of muscles, tendons, skin and nearby soft tissues that causes joints to shorten and become very stiff) for 2 of 2 residents reviewed for range of motion. (Residents 56 and 40)
- 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, record review, and interview, the facility failed to ensure an indwelling suprapubic (urinary) catheter tubing and collection bag was kept off the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 1)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control measures were in place and implemented related to a glucometer (blood sugar monitor) used for multiple residents and not cleaned and sanitized after each resident use. (RN 1) This had the potential to affect two residents on the 200 hall who received glucometer testing. The facility also failed to ensure a resident with a Multi-Drug Resistant Organism was placed on Enhanced Barrier Precautions (EBP) as ordered. (Resident 71)
October 25, 2023Standard inspection · 6 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 observation and interview, the facility failed to ensure a sanitary kitchen related to built up burnt food debris on the stove top and bottom inside of the convection oven. There was a build up of grease inside the convection oven doors, back splash on the oven, and side of the oven for 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect 96 residents who received food from the kitchen.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of a scabbed area on the skin for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 68)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a Physician's Order was in place for a palm protector for treatment of limited range of motion for 1 of 1 residents reviewed for range of motion. (Resident 40)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration flow rate for 1 of 1 residents reviewed for respiratory care. (Resident 1)
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a Physician initiating antibiotic therapy for a non-true infection based on the McGreer's Criteria and prescribing a resistant antibiotic based on urine culture results for 1 of 1 residents reviewed for urinary tract infections. (Resident 28)
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview, the facility failed to have the results of the State survey findings easily accessible for all residents to review. This had the potential to affect the 99 residents who resided in the facility.
Fire safety inspections
13 fire safety citations on file: 10 on January 6, 2026, 3 on November 1, 2024.
Every fire safety citation13 citations
- F
Implement emergency and standby power systems.
E 41 · January 6, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · January 6, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 6, 2026 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · January 6, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · January 6, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 6, 2026 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 6, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 6, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 6, 2026 · 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 · January 6, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 1, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 1, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 1, 2024 · Corrected (the home has a date of correction)