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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
3E
1F
Potential for minimal harm
0A
0B
0C
June 17, 2026Standard inspection · 1 citation
- D
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, it was determined that the facility failed to store food in a sanitary manner by ensuring opened food items were properly labeled with the date opened. This is evident for 1 of 1 kitchen areas reviewed.
May 1, 2025Standard inspection, Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of a facility reported investigation and staff interviews, it was determined that the facility failed to report an allegation of abuse to the law enforcement agency. This was evident for 2 (Resident #11 and #13) out of 3 residents reviewed for facility reported investigations during the facility's Medicare/Medicaid recertification survey.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on resident interview, record review, and staff interview, it was determined that the facility failed to notify the ombudsman of a resident's transfer to the hospital. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospitalizations.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on resident interview, record review, and staff interview, it was determined that the facility failed to provide the bed-hold policy to a resident or resident representative before the resident was transferred to the hospital. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospitalizations. A bed-hold policy addresses holding a resident's bed during periods of absence, such as during hospitalization or therapeutic leave.
March 17, 2021Standard inspection · 10 citations
- F
Post nurse staffing information every day.
Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. Additionally, the facility name was not on the form. This was observed for at least 4 of the 7 survey days.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review and staff interview it was determined: 1) the pharmacist failed to identify a medication order discrepancy during a monthly pharmacy medication review and 2) facility staff failed to have a process to ensure that pharmacy recommendations were acted upon by the physician. This was evident for 2 (#3, #8) of 5 residents reviewed for unnecessary medications and 1 of 4 residents reviewed for pressure ulcers (Resident #14).
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was evident for 3 of 27 residents reviewed during the annual survey (Residents #7, #12 and #31).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 of 5 residents reviewed for unnecessary medication (Resident #8).
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to treat resident with dignity and respect by labeling and identifying resident's as feeders. This was identified for 7 of 24 residents in the facility at the initiation of the survey (Residents #6, #11, #13, #15, #23, #29 #74) .
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, resident and staff interview it was determined that facility staff failed to have a call bell in reach for a resident who was dependent on staff for activities of daily living. This was evident for 1 of 17 residents observed in the initial resident pool (Resodemt #17) .
- 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 medical record review and staff interview it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 of 2 residents reviewed for accidents (Resident #17).
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 of 27 residents reviewed during an annual refortification survey (Resident #24) .
- 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 medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #14).
- 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 observations and interviews, it was determined that the facility failed to ensure that medications requiring refrigeration were stored safely. This was found to be evident in 1 out of 1 medication storage rooms and had the potential to affect all residents.
Fire safety inspections
7 fire safety citations on file: 2 on May 1, 2025, 5 on March 17, 2021.
Every fire safety citation7 citations
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 1, 2025 · 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 17, 2021 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 17, 2021 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 17, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 17, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 17, 2021 · Corrected (the home has a date of correction)