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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
1E
2F
Potential for minimal harm
0A
0B
0C
June 10, 2026Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, review of the facility's water management plan, review of laboratory test results, and review of the facility weekly logbook documentation of tasks completed, the facility failed to ensure an effective water management and legionella prevention plan were implemented. This had the potential to affect all 75 residents residing in the facility. Findings Include: Review of the facility Water Management Plan, dated 04/18/25 revealed a diagram of the water system, analysis of building water systems, control measures, monitoring/corrective actions, confirmation and documentation. [...]
July 31, 2025Standard inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on closed resident record reviews, hospital discharge instructions, and staff interview, the facility failed to ensure care for nephrostomy tubes was provided in a timely manner. This affected one resident (#77) of one reviewed for hospitalizations. The facility census was 77.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on resident record reviews, staff interview, and review of facility policy, the facility failed to ensure resident influenza and pneumococcal vaccinations were offered and administered in a timely and appropriate manner. This affected two residents (#14 and #15) out of the five residents reviewed for immunizations. The facility census was 77.
April 29, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (Resident #36) of three residents reviewed for abuse. The facility census was 78.
October 5, 2023Standard inspection · 5 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected three (Resident #6, Resident #40, and Resident #49) of four residents reviewed for PASRR documents. The census was 72. Findings Include: 1. Resident #6 was admitted to the facility on [DATE]. His diagnoses were dementia, schizoaffective disorder, dysphagia, falls, hyperlipidemia, myocardial infarction, depression, obstructive uropathy, chronic pain, anemia, hypertension, anxiety, dysphagia, altered mental status, acute kidney disease, cervicobrachial syndrome, and restless leg syndrome. Review of his Minimum Data Set (MDS) assessment, dated 07/09/23, revealed he was minimally impaired. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility to adequately assess and provide treatment for Resident #64 who had red, dry, flaky scalp. This affected one (Resident #64) of two residents reviewed for activities of daily living. The facility census was 72.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review and review of facility policy revealed the facility failed to implement non-pharmacological interventions for Resident #48 prior to administering as needed narcotic pain medications. This affected one resident (Resident #48) reviewed for pain management. The facility census was 72.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide care and services to address Resident #48's verbalization of being sad and depressed. This affected one resident (Resident #48) reviewed for behavioral-emotional issues. The facility census was 72.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, medical record review, and facility policy review revealed the facility failed to ensure the proper storage of nebulizer machine mask to prevent contamination and possible infection. This affected one resident (Resident #173)out of one resident reviewed for respiratory care. The facility census was 72.
March 14, 2022Standard inspection · 11 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interview, resident interview, observations, medical record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to provide hand hygiene between resident care, while passing meal trays, and to wear gloves with direct resident care. This directly affected eleven Resident's (#36, #1, #29, #22, #28, #39, #272, #273, #53, #270, #271) but had the potential to affect all 59 residents residing in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to provide nail care, shaving, and haircuts, showers, and mouth care to residents who needed assistance. This affected five (Resident's #5, #9, #33, #28 and #36) of seven residents reviewed for activities of daily living (ADL). The facility census was 59.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to place call lights within resident reach. This affected two (Resident's #39 and #28) of two residents reviewed for call lights. The facility census was 59.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interview and medical record review, the facility failed to complete a correct Preadmission Screening and Record Review (PASARR). This affected one (Resident #39) of one resident reviewed for PASARR completion. The facility census was 59.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview, record review, and policy review the facility failed to create baseline care plans upon admission to the facility. This affected three (Resident's #53, #272 and #273) of the five newly admitted residents reviewed who still resided in the facility. The facility census was 59.
- 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, record review, staff interview and policy review, the facility failed to develop a comprehensive plan of care in the area of hospice and oxygen use for two (Resident's #9 and #26). This affected two of 22 sampled residents. The facility census was 59.
- 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, staff interview, resident interview, medical record review, and facility policy review, the facility failed to update Resident #33's care plan. This affected one (Residents #33) of two residents reviewed for care plans. The facility census was 59.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, interviews, and policy review the facility failed to administer insulin as ordered by the physician. This affected one Resident (#273) of the five residents reviewed for unnecessary medications. Additionally, the facility failed to identify, assess, and monitor one Resident's (#9) multiple bruising to face and bilateral arms. This affected one Resident (#9) of one resident reviewed for anticoagulant medication side effects. The facility census was 59.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to arrange audiology care for Resident #33 who was hard of hearing (HOH). This affected one Resident (#33) of two residents reviewed for ancillary services (hearing/vision). The facility census was 59.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed apply a WanderGuard (a device to prevent wander-prone residents from leaving unattended) to Resident #33 per physician orders. This affected one Resident (#33) of one resident reviewed for WanderGuards. The facility census was 59.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on staff interview, observations, medical record review, and facility policy review, the facility failed to administer oxygen per physician orders for Resident #26 and failed to store the BiPAP (bilevel positive airway pressure) mask properly for Resident #9. This affected two residents (Resident's #9 and #26) of four residents reviewed for respiratory care. The facility census was 59.
Fire safety inspections
9 fire safety citations on file: 2 on July 31, 2025, 2 on October 5, 2023, 5 on March 14, 2022.
Every fire safety citation9 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 31, 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 · July 31, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 5, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 14, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 14, 2022 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 14, 2022 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · March 14, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 14, 2022 · Corrected (the home has a date of correction)