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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
5D
3E
2F
Potential for minimal harm
0A
0B
0C
February 26, 2026Standard inspection · 3 citations
- 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 observation, interview, and record review, the facility failed to assess, monitor, and provide timely medical interventions for a resident with cloudy urine, thick sediments and an indwelling catheter. This applies to 1 of 1 resident (R10) reviewed for urinary tract infection (UTI) and catheter care in the sample of 18.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review the facility failed to document pain assessment, failed to document in the eMAR (electronic Medical Administration Record) the opioid medication that was administered, and failed to monitor and document for the effectiveness and/or adverse effects of the administered opioid medication to ensure that a resident's pain was managed. This applies to 1 of 4 residents (R87) reviewed for pain management in the sample of 18.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene and gloving during eye medication administration and blood glucose monitoring. The facility also failed to implement enhanced barrier precautions and use personal protective equipment during wound care. This failure applies to 3 of 3 residents (R10, R68, and R88) reviewed for infection control in a sample of 18.
January 24, 2025Standard inspection · 6 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 maintain the kitchen in a manner to prevent foodborne illness. This applies to 77 residents in the facility receiving dietary services.
- E
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed to self-administer medications and keep them at their bedsides. This applies to 4 of 4 residents (R9, R34, R235, R237) reviewed for medication storage in a sample of 23.
- E
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 safely transfer, position, and implement fall prevention interventions for residents at risk for falls. This applies to 4 out of 6 residents (R55, R285, R49, R12) reviewed for safety and accidents in a sample of 23.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rooms with sharps disposal containers were safely maintained. This applies to 5 residents (R3, R73, R287, R79, and R39) reviewed for facility environment in a sample of 23.
- 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 observation, interview, and record review, the facility failed to ensure residents were provided with a warm, comfortable room. This applies to 2 out of 3 residents (R77 and R67) reviewed for homelike environment in a sample of 23.
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident beds were safely maintained. This applies to 2 out of 3 residents (R55 and R14) reviewed for resident equipment in a sample of 23 1. R14 MDS (Minimum Data Set) dated 1/3/25, shows he is cognitively intact. R14 requires substantial staff assistance with repositioning in bed and is dependent on staff transfers between the bed and chair. R14's current care plan includes an ADL (Activities of Daily Living) self-care deficit related to mobility deficits and weakness. On 01/21/25 at 11:33 AM, R14 was on an airloss mattress with approximately four inches of his bed frame exposed on each side of his bed. On 01/23/25 at 11:59 AM, R14 was still on an air mattress with approximately four inches of his bed frame exposed on each side of his bed. [...]
January 2, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's non-healing, chronic wounds were assessed by a physician, failed to do a wound assessment prior to a resident's discharge from the facility, and failed to provide wound treatments as ordered by the physician. This failure resulted in R1 being admitted to the hospital within 25 hours of discharge from the facility with a diagnosis of gangrene of the left first, second, and third toes, and requiring a left, above the knee leg amputation. This applies to 8 of 8 residents (R1, R2, R3, R4, R5, R6, R7, and R8) reviewed for wound care in the sample of 8.
February 16, 2024Standard inspection · 1 citation
- 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 properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.
Fire safety inspections
13 fire safety citations on file: 3 on January 24, 2025, 4 on February 16, 2024, 6 on March 30, 2023.
Every fire safety citation13 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · January 24, 2025 · 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 · January 24, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 24, 2025 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · February 16, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 16, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 16, 2024 · 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 · March 30, 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 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 30, 2023 · Corrected (the home has a date of correction)