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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
8E
1F
Potential for minimal harm
0A
0B
0C
February 11, 2026Complaint inspection · 6 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteThis citation pertains to intake #2685190Based on observation, interview and record review, the facility failed to consistently ensure the readiness of the nurse's emergency crash cart.
- E
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wrote710 Physician servicesThis citation pertains to intake #s 2638540 2724503, 2676090Based on interview and record review, the facility failed to ensure the medical provider adequately supervised the care of one Resident (R103) of four residents reviewed for physician services.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteThis citation pertains to intake# 2685190Based on observation, interview, and record review, the facility failed to store medication and biologicals in accordance with manufacturer's recommendations.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteThis citation pertains to intake #s 2638540 and 2676090Based on interview and record review, the facility failed to ensure clear and concise documentation in the Electronic Medical Record for one Resident (R103) of three residents reviewed for medical record accuracy.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteCitation pertains to intake #2676090Based on interview and record review, the facility failed to notify the medical provider of a new open wound for one resident (R103) of 4 residents reviewed for notifications when one resident (R103) developed an open wound.
- 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 wroteThis citation pertains to intake #s 2676090 and 2658540Based on interview and record review, the facility failed to revise the comprehensive care plan and formulate goals and interventions when one facility Resident (R103) developed an open wound of four residents reviewed for care plans.
July 31, 2025Standard inspection · 8 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, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and to spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 dependent residents (R5 and R20) of 4 residents reviewed for availability of call lights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a fall with injury for 1 resident (R2) of 2 residents reviewed for falls.
- 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 interview and record review, the facility failed to implement care planned fall interventions for 1 resident (R2) of 2 residents reviewed for falls.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, the facility failed to correctly label an ordered tube feeding for one resident (Resident #69) out of three residents reviewed for tube feeding.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to (a) offer ordered nebulizer treatments and (b) adequately clean nebulizer equipment for one resident (Resident #1) out of two residents reviewed for respiratory care.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to accurately document narcotic administration for one of three residents (Resident #4) reviewed for pharmacy services.
August 28, 2024Standard inspection · 4 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate smoking supervision and monitoring for 5 of 14 residents (Resident #25, #1, #27, #26, and #13) reviewed for accidents and safety.
- 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 (EBP) and Transmission Based Precautions (TBP) were in place and followed for 3 residents (Resident #64, #217, and #21) of 4 residents reviewed for Precautions, resulting in the increased potential for cross-contamination, bacterial harborage and spread of infection throughout the facility.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving tube feedings per facility policy and professional standards of care for 1 of 3 residents (Resident #61) reviewed for the care of tube feedings.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal and influenza vaccination to 1 resident (Resident #29) of 5 residents reviewed for immunizations, resulting in the potential for residents to contract and spread preventable diseases.
December 6, 2023Complaint inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers for 1 resident (Resident #5) out of 2 residents reviewed for pressure ulcers.
August 25, 2023Standard inspection · 2 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, interview, and record review, the facility failed to maintain kitchen plumbing and properly cool potentially hazardous food, resulting in the potential for contamination of the physical facility and biological contamination of food products. These deficient practices affect all residents that consume food from the kitchen.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Doctor's Orders were followed for the administration of medication for two Residents (Resident #7 and Resident #13), resulting in medication administered outside parameters and/or the potential for an adverse outcome Resident #7 (R7) Review of the Electronic Medical Record (EMR) reflected R7 originally admitted to the facility 1/21/22 with pertinent diagnosis that included: Essential Hypertension, Atrial Fibrillation, and Syncope and Collapse. Review of the Doctor's Orders (DO) for R7 revealed three medications were ordered to not be given if the Resident's heart rate was below 65 beats per minute (bpm). These included: Clonidine 0.1 milligrams (mg) ordered to be administered three times a day, Metoprolol 25 mg 1 tablet twice daily, and Amiodarone 200 mg in the morning. [...]
Fire safety inspections
13 fire safety citations on file: 2 on July 31, 2025, 5 on August 28, 2024, 6 on August 25, 2023.
Every fire safety citation13 citations
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 31, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 31, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · August 28, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 28, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 25, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 25, 2023 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 25, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 25, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 25, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 25, 2023 · Corrected (the home has a date of correction)