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 15 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
0E
1F
Potential for minimal harm
0A
0B
0C
May 8, 2026Standard inspection · 4 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on facility policy review, observation, and resident interview, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff on one of three nursing units. (Unit 1)
- 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, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to meet a resident's medical and physical needs for one of 35 sampled residents. (Residents 18)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow procedures to prevent accident hazards for one of 35 sampled residents. (Resident 162)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for one of two nursing units observed during medication administration. (Unit 1)
April 25, 2025Standard inspection, Complaint inspection · 8 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity for one of 34 sampled residents. (Resident 138)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 34 sampled residents. (Resident 471)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 34 sampled residents. (Resident 147)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 34 sampled residents. (Residents 19)
- 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of nine sampled residents with limited range of motion. (Resident 147)
- 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 facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of three sampled residents with an indwelling urinary catheter. (Resident 106)
- 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with the physician's order for one of two sampled residents receiving nutrition by a feeding tube. (Resident 58)
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on facility policy review, resident interviews, observation, and results of a test tray evaluation, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of three nursing units. (Second floor)
May 31, 2024Standard 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, it was determined that the facility failed to prepare and serve food under sanitary conditions in the kitchen.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess a significant weight change for one of seven sampled residents at risk for weight loss. (Resident 100)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services consistent with professional standards of practice for one of three residents receiving dialysis. (Resident 125)
Fire safety inspections
4 fire safety citations on file: 1 on April 25, 2025, 1 on May 31, 2024, 2 on July 18, 2023.
Every fire safety citation4 citations
- C
Have simulated fire drills held at unexpected times.
K 712 · April 25, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 31, 2024 · Corrected (the home has a date of correction)
- 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 18, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 18, 2023 · Corrected (the home has a date of correction)