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
2L
Actual harm
1G
0H
0I
Potential for more than minimal harm
12D
1E
1F
Potential for minimal harm
0A
0B
0C
May 8, 2026Complaint inspection · 2 citations
- L
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, clinical record review, review of facility's policies and procedures and staff interviews, the facility administration failed to provide effective oversight to ensure ongoing implementation of a water management program to reduce the risk of growth and spread of Legionella (water-borne disease causing bacteria), and failed to minimize the risk of ongoing exposure to Legionella for 145 residents from potentially contaminated water sources, in response to a resident's confirmed diagnosis of Legionnaires' Disease (potentially fatal form of pneumonia caused by Legionella bacteria) that may have been acquired at the facility.
- L
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, review of facility's policies and procedures, and interviews, the facility failed to establish and implement a water management program to mitigate the risk of Legionella (waterborne disease-causing bacteria) exposure. The facility failed to minimize the risk of ongoing exposure to Legionella from potentially contaminated water sources in response to a resident's confirmed diagnosis of Legionnaire's disease (potentially fatal form of pneumonia caused by Legionella bacteria) that may have been acquired at the facility.
May 8, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent falls for 2 (Residents #1 and #4) of 4 residents reviewed with multiple falls and/or fall related injuries.
December 19, 2024Standard 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, record review and staff interviews, the facility failed to ensure 1 (Dietary aide Staff N) of 1 staff observed operating the dishwasher was trained, and competent to test the sanitizing solution of the low temp dishwasher to ensure dishes were properly sanitized to prevent foodborne illnesses of residents consuming an oral diet.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, review of facility's policy and procedure, resident and staff interview, the facility failed to accommodate the needs of 1 (Resident #59) of 4 dependent residents reviewed by failing to place the call system within reach of the resident.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview and record review, the facility failed to revise the comprehensive care plans with resident centered interventions to ensure 1 (Resident #85 ) of 3 sampled residents reviewed achieved their highest practicable physical, mental and psychosocial wellbeing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, staff, resident and family interviews and review of facility policy and procedures the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #5, and #24) of 3 residents reviewed for activities of daily living (ADL's).
- 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 record review, staff, resident and family interviews and review of facility policy and procedures the facility failed to provide the necessary care and services to maintain continence for 1(Resident #5) and failed to maintain indwelling urinary catheters in a safe and sanitary manner for 2 (Resident #134 and #85) of 3 residents reviewed for bowel and bladder incontinence and urinary catheters.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, and resident and staff interview, the facility failed to store CPAP (continuous positive airway pressure) equipment in a sanitary manner for 3 (Resident #10, #70 and #14) of 3 resident's reviewed for respiratory care and sleep apnea. This had the potential to cause respiratory infections in compromised residents.
May 25, 2023Standard inspection · 6 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interviews, resident records review and facility policy review the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflects resident's oral status to identify dental care needs for 1 (Resident #123) of 3 residents reviewed for accuracy of assessment.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, clinical record review, review of facility guidelines manual, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #121) of 27 residents reviewed for activities of daily living (ADLs).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for 1 (Resident #144) of 2 sampled residents receiving intravenous medications.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to implement individualized care planned interventions to address the behavioral health needs of 1 (Resident #135) of 2 residents reviewed for behavioral health.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, review of facility policy and procedure, resident and staff interviews, the facility failed to ensure 1(Resident #62) of 5 residents reviewed for medication administration received the physician ordered intravenous antibiotic without unnecessary interruption to treat an infection in a surgical wound.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to provide timely assistance with referrals for outside oral surgery services to meet the needs of 1(Resident #123) of 3 residents reviewed for dental services.
September 30, 2021Standard inspection · 2 citations
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, policy review, staff, resident, and family interviews, the facility failed to ensure 7 (Resident #261, #31, #63, #49, #67, #257, and #8) of 10 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails or if an alternative was identified, why the alternative failed to meet the resident's need. In addition, the facility failed to have ongoing routine maintenance of the bed rails in accordance with manufacturer's recommendations.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident and staff interviews, record review, and review of facility policies and procedures, the facility failed to provide the necessary care and services to maintain grooming and hygiene for 3 (Resident #17, #63, and #101) of 3 dependent residents reviewed for assistance with activities of daily living. This has the potential to cause psychological harm to the resident.
Fire safety inspections
16 fire safety citations on file: 1 on May 8, 2026, 5 on December 19, 2024, 6 on May 25, 2023, 4 on September 30, 2021.
Every fire safety citation16 citations
- F
Meet other general requirements.
K 100 · May 8, 2026 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · December 19, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 19, 2024 · 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 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · May 25, 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 · May 25, 2023 · 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 · May 25, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Include a process for Emergency Preparedness collaboration.
E 9 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for medical documentation.
E 23 · May 25, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 30, 2021 · 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 30, 2021 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · September 30, 2021 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 30, 2021 · Corrected (the home has a date of correction)