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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
15D
5E
0F
Potential for minimal harm
0A
0B
0C
January 16, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure pressure ulcers (skin and tissue damage caused by prolonged pressure) were treated timely after admission for 3 of 3 residents reviewed for pressure ulcers (Residents B, C, and D).
May 16, 2025Standard inspection · 6 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff assessed a resident with a pressure ulcer and implemented treatments which resulted in harm due to the pressure ulcer worsening from a stage 1 (non-blanchable red intact skin) to a stage 3 (full thickness skin loss where fat tissue may be visible) before pressure ulcer assessments and treatments were started for 1of 2 residents reviewed for pressure ulcers (Resident 16).
- 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 observation, interview, and record review, the facility failed to ensure medication was labeled properly and the facility failed to ensure expired medication was disposed of for 2 of 2 medication storage rooms reviewed for medication storage (Resident 49).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteA. Based on interview and record review, the facility failed to prevent a delay in treatment after a fall with fracture for 1 of 3 residents reviewed for accidents (Resident 27). B. Based on record review and interview, the facility failed to ensure a treatment order was stopped or clarified after 60 days for 1 of 5 residents reviewed for unnecessary medications (Resident 30).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure a root cause analysis was completed and an intervention put in place after falls for 1 of 3 residents reviewed for accidents (Resident 27).
- 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 ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag (a bag that collects urine) did not touch the floor for 1 of 1 residents reviewed for catheter care (Resident 52).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper cleaning and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Residents 50 and 270).
March 18, 2024Standard inspection · 6 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 observation, interview, and record review, the facility failed to ensure beard restraints were worn in the kitchen serving area (on the skilled unit) and in the main kitchen food prep area for 2 of 2 kitchen observations.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately assess and document impairments in skin for 1 of 1 residents reviewed for skin impairments (Resident 15).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to address a significant weight discrepancy for 1 of 2 residents reviewed for nutrition (Resident 57).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask was stored properly when not in use and an self administration assessment was completed for 1 of 2 residents reviewed for respiratory care (Resident 113), and failed to ensure oxygen orders were in place for 1 of 2 residents reviewed for respiratory care (Resident 39).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure physician orders were followed for 2 of 5 residents reviewed for unnecessary medication review (Residents 35 and 37).
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for the resident to call for staff assistance when needed for 1 of 24 residents rooms observed for call light availability (Resident 34).
February 1, 2023Standard inspection · 8 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteA. Based on interview and record review, the facility failed to address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions of the Resident Council and the facility's grievance log. This potentially affected 63 of 63 residents who resided in the facility. B. Based on observation, interview, and record review, the facility failed to ensure a grievance provided during resident council was resolved for 1 of 1 resident reviewed for grievances (Resident 40).
- 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 ensure an effective fall management program and failed to ensure fall interventions were personalized, implemented, and care planned for 4 of 4 residents reviewed for accidents (Residents 36, 31, 40, and 35).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served, for 1 of 1 test tray reviewed for temperature and palatability. This had the potential to effect 59 of 59 residents who received food from the kitchen.
- 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 interview and record review, the facility failed to ensure resident shower choices were met for 1 of 24 residents reviewed for choices (Resident 25).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nail care was provided to a dependent resident for 1 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Resident 50).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were acted upon by the physician in a timely manner and that the physician provided rationale for decisions made on pharmacy recommendations, for 2 of 5 residents reviewed for unnecessary medications (Residents 21 and 35).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendation were reviewed and addressed by the physician for 2 of 5 residents reviewed for unnecessary medications (Residents 2 and 21).
- D
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 observation, interview, and record review, the facility failed to ensure medications, biologicals, and feeding tube formulas were labeled, stored, and destroyed according to policy for 1 of 4 medication carts observed, and 1 of 2 medication rooms observed for medication and biological storage.
Fire safety inspections
11 fire safety citations on file: 2 on May 16, 2025, 9 on February 1, 2023.
Every fire safety citation11 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 16, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · February 1, 2023 · Corrected (the home has a date of correction)
- E
Implement emergency and standby power systems.
E 41 · February 1, 2023 · 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 · February 1, 2023 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · February 1, 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 · February 1, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · February 1, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · February 1, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 1, 2023 · Corrected (the home has a date of correction)
- B
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 1, 2023 · Corrected (the home has a date of correction)