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
1G
0H
0I
Potential for more than minimal harm
14D
0E
2F
Potential for minimal harm
0A
0B
0C
September 18, 2025Standard inspection, Complaint inspection · 12 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 observations staff interviews, policy review, and record review, the facility failed to store and prepare foods and maintain the kitchen in a sanitary manner. This had the potential to affect 46 residents who received food from the kitchen. The facility census was 47.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure signed Do Not Resuscitate (DNR) paperwork was present in the chart for a resident who requested DNR code status. This affected one (#52) of 19 residents reviewed for advance directives. The facility census was 47.
- 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 record review, staff interviews, and facility policy review, the facility failed to ensure the physician was notified timely of a resident's change in condition. This affected one (#5) of one resident reviewed for notification of change in condition. The facility census was 47.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected one (#4) of 19 residents reviewed for MDS assessments. The facility census was 47.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure the resident's Pre-admission Screening and Resident Review (PASARR) were completed accurately following residents' significant changes in serious mental diagnosis. This affected three (#2, #9 and #13) of three residents reviewed for PASARR. 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 record review and staff interview, the facility failed to ensure residents had care plans in place for dementia care and history of severe weight loss. This affected two (#3 and #7) of 19 residents reviewed for care planning. The facility census was 47.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure the residents receive timely care and services during a change in condition and failed to obtain weights as physician ordered. This affected three residents (#1, #5, and #23) of four residents reviewed for changes in condition. The facility census was 47.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, record review, and review of facility policy, the facility failed to ensure the residents received timely assessments and treatment for pressure ulcers. This affected one (#34) of two residents reviewed for pressure ulcers. The facility census was 47.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure the appropriate fall interventions were in place to prevent falls and failed to ensure fall interventions were updated on the plan of care following a fall. This affected one (#34) of four residents reviewed for falls. The facility census was 47.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on medical record review, and resident and staff interviews, the facility failed to ensure a resident was assessed and received trauma informed care accounting for the resident's experiences with spousal abuse. This affected one (Resident #42) of one resident reviewed for trauma informed care. The facility census was 47.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#34) of seven residents reviewed for medication administration. The facility census was 47.
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on medical record review, staff interviews, and review of the facility's radiology contract, the facility failed to obtain stat (immediately) x-rays in a timely manner. This affected one (#5) of one resident reviewed for radiology services. The facility census was 47.
November 7, 2023Standard inspection · 2 citations
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on medical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure residents had access to personal funds on the weekends. This affected one resident (#38) out of the five residents reviewed for personal funds during the annual survey. The facility census was 47.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review and staff interview the facility failed to ensure accurate advance directives were included in the residents' medical records. This affected one (Resident #21) of one residents reviewed for advanced directives. The facility census was 47.
July 8, 2021Standard inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide appropriate supervision to a resident while eating that was at high risk for choking. This resulted in actual harm when Resident #11 was left unsupervised alone, in the room to eat and the resident choked on food, requiring the Heimlich Maneuver to be performed. Subsequently the resident developed aspiration pneumonia requiring treatment. The facility failed to provide supervision again for the resident during a meal observation of the resident eating alone in the room. This affected one (#11) of the three residents sampled for assistance with Activities of Daily Living (ADL). The facility census was 48.
- 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, recipe review, policy reviews and staff interviews, the facility failed to appropriately store and prepare food items. This had the potential to affect 48 of 48 residents who resided in the facility and received their meals from the kitchen.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to accurately assess a residents teeth. This affected one (#19) of one residents reviewed for dental. The faciltiy census was 48. Findings Include: Review of the Resident #19's medical record revealed an admission date of 01/18/21, with the admitting diagnoses of diabetes mellitus, right below the knee amputation, malignant neoplasm of prostate, hypertension, major depressive disorder and congestive heart failure. Review of the resident's admission assessment dated [DATE] revealed the the assessment failed to identify if the resident had natural teeth, dentures or was edentulous. Review of the resident's comprehensive minimum data set (MDS) assessment dated [DATE], revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit. [...]
Fire safety inspections
17 fire safety citations on file: 3 on September 18, 2025, 5 on November 7, 2023, 9 on July 8, 2021.
Every fire safety citation17 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 7, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 7, 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 · November 7, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 7, 2023 · 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 7, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 8, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 8, 2021 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 8, 2021 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 8, 2021 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 8, 2021 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · July 8, 2021 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 8, 2021 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 8, 2021 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 8, 2021 · Corrected (the home has a date of correction)