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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
9D
4E
0F
Potential for minimal harm
0A
0B
0C
May 14, 2026Standard inspection · 3 citations
- 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 wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of seven medication carts and two of three medication storage rooms. Specifically, the facility failed to: -Ensure ophthalmic solutions were labeled with the date when the medications were opened;-Ensure there were no loose pills in the bottom of the medication cart drawers; and,-Ensure that lorazepam and insulin vials were labeled with the dates the medications were opened.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure food was held at the correct temperature.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, record review and interviews the facility failed to maintain accurately documented medical records for one (#13) of four residents reviewed for ADLs out of 40 sample residents. Specifically, the facility failed to:-Ensure Resident #13's bathing record was accurately documented related to whether the resident received or refused her scheduled bed baths; and,-Ensure Resident #13's care plan included documentation to indicate the resident refused her offered bed baths at times.
June 19, 2025Complaint 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 record review and interviews, the facility failed to ensure one (#1) of five residents reviewed for accident hazards received adequate supervision out of 12 sample residents. Resident #1 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, muscle weakness and reduced mobility related to left lower leg fractures sustained prior to admission to the facility. Resident #1 was dependent on two staff members providing maximum physical support/ assistance to complete positioning and transfer activities of daily living (ADL). Resident #1 had severe cognitive impairments, per staff interview, and was unable to understand the operation of the bed controls safely or appropriately (see staff interviews below). [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an allegation for an injury or unknown origin for one (#1) of two residents out of 12 sample residents. Specifically, the facility failed to complete a thorough investigation to clarify conflicting facts after Resident #1 sustained an injury of unknown origin to her left lower leg (fractured tibia and fibula), which required hospitalization and surgical intervention.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the services provided met professional standards of quality for one (#1) of seven residents out of 12 sample residents. Specifically, the facility failed to ensure Resident #1 was assessed by a registered nurse (RN) after a significant change of condition when she experienced a fracture of the left fibula and tibia (lower leg bones).
May 9, 2024Standard inspection, Complaint inspection · 2 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, temperature and texture.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased upon observations, interviews and record review, the facility failed to ensure two (#65 and #69) of five residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #65 fingernails were trimmed and clean; and, -Ensure Resident #69 received staff assistance with fingernail care, applying lotion on his dry skin and showering assistance.
January 26, 2023Standard inspection · 6 citations
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure two (#5 and #23) of two residents reviewed for communication out of 50 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #5 and Resident #23, who spoke a language other than English.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interviews and record review, the facility failed to honor resident choices for one (#357) of three out of 50 sample residents. Specifically, the facility provide Resident #357 bathing according to her preference.
- 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 interviews, the facility failed to develop a comprehensive care plan for two (#82 and #51) out of 50 sample residents for services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure the comprehensive care plan addressed Resident #82 and Resident #51's nutritional status and needs.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#36) of four out of 50 sample residents. Specifically, the facility failed to meet Resident #36's socialization needs.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#62) of seven out of 50 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure that Resident #62 received a prescribed wound treatment after every incontinence episode on a coccyx wound.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews, and record review the facility failed to honor food preferences for one (#28) of four residents reviewed out of 50 sample residents. Specifically the facility failed to ensure Resident #28's requests and preferences for gluten free foods were served to her.
Fire safety inspections
16 fire safety citations on file: 7 on May 14, 2026, 1 on May 9, 2024, 8 on January 26, 2023.
Every fire safety citation16 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 14, 2026 · deficient, provider has
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 14, 2026 · deficient, provider has
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 14, 2026 · deficient, provider has
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 14, 2026 · deficient, provider has
- D
Have properly located and lighted "Exit" signs.
K 293 · May 14, 2026 · deficient, provider has
- D
Provide properly protected cooking facilities.
K 324 · May 14, 2026 · deficient, provider has
- D
Have an externally vented heating system.
K 522 · May 14, 2026 · deficient, provider has
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 9, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 26, 2023 · Corrected (the home has a date of correction)