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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
0E
1F
Potential for minimal harm
0A
0B
0C
March 26, 2026Standard inspection · 1 citation
- 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 ensure Physician Orders were being followed as ordered for the correct resident for 3 of 6 residents (R22, R77 and R78) reviewed for medication errors in the sample of 37.
November 22, 2024Standard inspection · 4 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 ensure food was stored and prepared in a manner that prevents foodborne illness. This has the potential to affect all 62 residents living in the Facility.
- D
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 preventative measures for a safe transfer, free of hazards from one level to the next for 2 out of 8 residents (R39, R59) for falls in a sample of 43. 1. R59's Face Sheet undated documents her pertinent diagnosis as age related physical debility and repeated falls. R59's Minimum Data Set (MDS) dated [DATE] documents R59 has moderate cognitive impairment and is dependent in transferring from sit to stand, chair to bed, toilet, and tub transfer. R59's Fall Risk admission dated 7/26/24 documents High Risk for Falls. Nurse Progress notes dated 11/6/24 documents R59 lost her balance during a transfer from wheelchair to recliner and fell to her right side, staff was present with her. [...]
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure food was prepared according to physician prescribed diet orders for 3 of 3 residents (R6, R38, R47) reviewed for therapeutic diets in the sample of 43.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review the facility failed to provide antibiotic stewardship for 1 of 2 residents (R116) reviewed for antibiotic stewardship in the sample of 43. Findings Include: The facility's Infection Control Log dated 7/2/24 documents R116 prophylactic use admitted with a UTI (Urinary Tract Infection). The Infection Control Log also documented that R116 received Methenamine Hippurate 1 gram. R116's Nurses Note dated 7/9/24 documents V33 (Attending Physician) gave okay to check a UA (Urinalysis) and C&S (Culture and Sensitivity) to R/O (Rule Out) UTI. PT (Patient) cont. (continues) to c/o (complain of) UTI symptoms. She (R116) is on prophylaxis ABX (antibiotic) daily now and UA on 7/3 was neg (negative). Son cont. to request UA. [...]
March 27, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse, for 2 of 2 residents (R2 and R13) reviewed for abuse, in the sample of 18.
December 13, 2023Standard inspection · 1 citation
- D
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 utilize a gait belt while transferring a resident and failed to ensure that fall interventions were put into place for 2 of 15 residents (R116 and R21) reviewed for falls in the sample of 41.
Fire safety inspections
6 fire safety citations on file: 1 on March 26, 2026, 2 on November 22, 2024, 3 on December 13, 2023.
Every fire safety citation6 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 26, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 22, 2024 · 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 · November 22, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 13, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 13, 2023 · Corrected (the home has a date of correction)
- D
Install a two-hour-resistant firewall separation.
K 133 · December 13, 2023 · Corrected (the home has a date of correction)