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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
2E
1F
Potential for minimal harm
0A
0B
0C
May 20, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interview, record review, review of the facility's Self-Reported Incidents (SRI), and policy review the facility failed to report an allegation of abuse to the state agency. This affected one (#53) of the three residents reviewed. The facility census was 51.
January 16, 2025Standard inspection · 2 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 record review, staff interview, and review of the facility policy, the facility failed to ensure care plans were accurate and current. This affected two residents, (#10 and #20) out of five residents reviewed for care plans. The current census was 53.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on observation, staff interviews and review of facility policy, the facility failed to ensure proper infection control measures wre followed for nephrostomy collection bag. This affected one Resident #144 of two reviewed for urinary catheter care. The facility census was 53.
August 25, 2022Standard inspection · 7 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure resident smoking supplies were stored in a locked area. This affected one (Resident #7) out of one resident reviewed for smoking and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (Resident #34) out of one resident reviewed for self-administration of medication and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47.
- 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 medical record review and staff interview, the facility failed to ensure a care plan was developed to address resident medical diagnoses. This affected three (Resident #18, #23, and #103) out of 11 residents reviewed for care plans. The facility census was 47.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure staff trimmed the fingernails of residents who were unable to carry out activities of daily living. This affected one (Resident #22) out of 47 residents reviewed for personal hygiene. The facility census was 47.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents blood sugar levels were checked as ordered. This affected two (Resident #7 and #29) out of five residents reviewed for unnecessary medications. The facility census was 47.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to maintain and store a rigid suction catheter in clean and sanitary manner. This affected one (Resident #20) out of one resident reviewed for respiratory suctioning. The facility census was 47.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure wound measurements were accurately documented on a wound assessment. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 47.
August 29, 2019Standard inspection · 3 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 observation, staff interview and facility policy review the facility failed to maintain the kitchen in a clean manner, failed to store foods as per guidelines and failed to ensure proper sanitation of utensils, pots and pans while using the sink. This had the potential to effect all 44 residents residing in the facility.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review, observation staff interview, and review of manufacturer guidelines, the facility failed to ensure a resident's insulin was administered according to manufacturer guidelines, resulting in a significant medication error. This affected one Resident (#5) of two residents observed for insulin administration. The facility identified three residents receiving insulin. The facility census was 44.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview and facility policy review the facility failed to implement appropriate hand hygiene during a dressing change. This effected one Resident (#5) of two observed for dressing changes. The facility census was 44.
Fire safety inspections
7 fire safety citations on file: 3 on January 16, 2025, 3 on August 25, 2022, 1 on August 29, 2019.
Every fire safety citation7 citations
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 25, 2022 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · August 25, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 25, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 29, 2019 · Corrected (the home has a date of correction)