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
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
10D
3E
0F
Potential for minimal harm
0A
0B
0C
May 13, 2026Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and interviews with staff, Contractor for safety systems, and the Medical Director, the facility failed to effectively supervise a resident, who had diagnoses including dementia and altered mental status and a history of falls, from exiting the facility unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was admitted to the facility on [DATE] and according to staff became increasingly confused during the shift which started at 7:00 PM. Resident #1 got out of bed multiple times and self-propelled in his wheelchair up and down the hall and was observed at the exit door looking out the window. [...]
September 11, 2025Standard inspection · 5 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 observations, and Dietitian and staff interviews, the facility failed to label and date leftover food items stored for use in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and the dry goods storage area and failed to maintain clean food service equipment and flooring and failed to clean a thermometer probe before inserting the probe into food. These practices had the potential to affect food served to residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility failed to ensure a resident was spoken to in a dignified manner when the resident expressed feelings of being frustrated and felt like he was spoken to in a childlike manner. This affected 1 of 3 residents reviewed for dignity and respect (Resident #30).
- 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 update 2 of 3 residents advance directive information (Resident #15 and Resident #18).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to provide nail care for 3 of 4 residents that were dependent on staff for personal care (Resident #2, Resident #26, and Resident #18).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to post cautionary signage for oxygen in use for 2 of 3 residents reviewed for respiratory care (Resident #25 and Resident #38).
July 23, 2024Standard inspection, Complaint inspection · 4 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, observations, staff, and physician interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #12). Nursing assistant (NA) #1 rolled Resident #12 away from her during incontinence care and Resident #12 rolled out of bed. Resident #12 sustained a fractured tibia and fibula (bones below the right knee). Resident #12 required a 2-day hospitalization for the fracture and returned to the facility with a leg brace in place.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to provide routine medications for 1 of 3 residents reviewed for medication administration (Resident #2).
- 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 and staff interviews, the facility failed to notify the physician of missed medication administration for 1 of 2 residents reviewed for notification (Resident #2).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to handle soiled linens in a manner to prevent the spread of infection for 1 of 1 laundry room observation.
September 28, 2023Standard inspection, Complaint inspection · 5 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessments for 7 of 14 residents reviewed for MDS accuracy. Resident #14 was not coded for Level II Preadmission Screening and Resident Review (PASRR) and inaccurately coded for daily restraint use. Residents #8, #5, #9, #13, #1 and Resident #6 were also inaccurately coded for daily restraint use.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents investigated for abuse from resident-to-resident sexual abuse (Resident #19).
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility failed to protect resident's bank debit cards, checks and credit cards from being accessed and used without resident permission for 3 of 3 residents reviewed for misappropriation of personal bank accounts (Resident #2,Resident #18, and Resident #14).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews, observations, and staff interviews, the facility failed to assess injuries after an unwitnessed fall for 1 of 3 residents reviewed for accidents (Resident #6).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to protect residents and staff from COVID-19 exposure and infection after a medication aide (MA#1) reported to work with signs and symptoms of COVID-19 and worked her shift before testing positive for COVID-19. MA #1 failed to notify the facility administration of the positive test result. 11 out of 21 residents were reviewed for COVID (Resident #4, Resident #9, Resident #18, Resident #13, Resident #3, Resident #2, Resident #15, Resident #17, Resident #123, Resident #124, and Resident #19) and 6 out of 35 staff (MA #2, Nursing Assistant #3, Nursing Assistant #4, Assistant Director of Nursing, MA #3, and Maintenance Director) tested positive for COVID-19.
Fire safety inspections
9 fire safety citations on file: 3 on July 23, 2024, 2 on September 28, 2023, 4 on June 9, 2022.
Every fire safety citation9 citations
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 23, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 23, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 28, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 28, 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 · June 9, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 9, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 9, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 9, 2022 · Corrected (the home has a date of correction)