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
18D
2E
0F
Potential for minimal harm
0A
0B
0C
July 29, 2025Standard inspection · 3 citations
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care and heel protectors were provided and a podiatry visit was completed for 2 of 2 residents reviewed for foot care. (Resident 37 and Resident 56)
- 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 an indwelling catheter drainage bag was free of the contact with the floor for 1 of 2 residents reviewed for urinary catheter usage. (Resident 86)
- 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 appropriate storage of a medicated cream for 1 or 3 residents reviewed for medication administration. (Resident 86)
April 16, 2025Complaint inspection · 2 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure misappropriation of residents' medication did not occur for 2 of 4 residents reviewed for abuse. (Resident B and Resident E) This deficient practice was corrected on 3/13/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systematic plan that included the following actions: in-service education to nursing staff on medication administration and documentation, assessment of residents, and signing out controlled medications. The facility conducted an audit of all narcotic count sheets for all residents receiving narcotic medications and conducted interviews and assessments of all residents for pain with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to complete pain assessments for 1 of 4 residents reviewed for pain medication and assessments. (Resident B) This deficient practice was corrected on 3/13/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systematic plan that included the following actions: in-service education to nursing staff on medication administration and documentation, assessment of residents, and signing out controlled medications. The facility conducted an audit of all narcotic count sheets for all residents receiving narcotic medications and conducted interviews and assessments of all residents for pain with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review.
June 5, 2024Standard inspection, Complaint inspection · 7 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents had water or beverages of choice available for 4 of 4 residents reviewed for accommodation of needs. (Resident 2, Resident 89, Resident 54, and Resident C)
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide their scheduled activity program on the Cottage Unit of the facility; implement and educate staff regarding a residents' individualized activity care plan; and redirect a resident with a history of wandering into other residents' rooms for 7 of 28 residents on the Cottage Unit of the facility. (Residents 6, 49, 35, 52, 60, 65, and 92)
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to fill out a grievance regarding missing items for 1 of 2 residents interviewed for missing items. (Resident 92)
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review the facility failed to prevent sexual abuse of two residents (Resident C and Resident F) perpetrated by (Resident E) and failed to prevent verbal abuse for (Resident B) for 3 of 5 residents reviewed for abuse.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a resident had compression stockings in place without wrinkles for 3 of 4 observations of Resident 94's compression stockings.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, observation, and record review, the facility failed to implement a fall intervention of a sign in Resident 88's room to encourage the use of a call light for a resident with a moderate fall risk and recent history of a fall for 1 of 2 residents reviewed for falls.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive eating equipment, fortified juice, and whole milk to 3 of 6 residents reviewed for nutrition. (Residents 6, 58, and 65)
February 15, 2024Complaint 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 interview and record review, the facility failed to ensure a fall from a mechanical lift did not occur during a transfer from the bed to the chair, resulting in cervical and thoracic fractures of the spine, for 1 of 3 residents reviewed for falls. (Resident B) The deficient practice was corrected on 1-10-24, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments of the resident who had experienced a fall, conduct neurological checks, and audits related to fall events.
May 9, 2023Standard inspection · 8 citations
- 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 failed to provide oral care for a dependent resident and nail care for a dependent resident for 2 of 5 residents reviewed for Activities Of Daily Living (ADL) (Resident 49 and Resident 27).
- D
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 assess and document abrasions on a cognitively impaired resident. This affected 1 of 2 residents reviewed for non-pressure related skin conditions. (Resident 73)
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review the facility failed to assess and implement an intervention for a resident with bilateral hand contractures for 1 of 2 residents reviewed for limited range of motion (Resident 27).
- 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 promote an environment to safeguard potentially hazardous chemicals by leaving a bottle of covid reagent solution on Resident 58's table for 1 of 1 residents reviewed for accidental hazards. (Resident 58)
- 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 interview, observation, and record review, the facility failed to ensure that urinary catheter tubing remained off of the floor for Resident 32 while sitting in the wheelchair for 1 of 3 residents reviewed for urinary catheters. (Resident 32)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a physician order for parenteral fluids had the correct route and included a rate and failed to document total volume of fluids infused for Resident 6 for 1 of 1 reviewed for parenteral fluids. (Resident 6)
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on interview and observation, the facility failed to follow dietary menus as written for 2 of 5 meals observed.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to accurately complete a weekly skin assessment for 1 of 36 residents reviewed for complete and accurate records. (Resident 73)
Fire safety inspections
14 fire safety citations on file: 6 on July 29, 2025, 5 on June 5, 2024, 3 on May 9, 2023.
Every fire safety citation14 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 29, 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 · July 29, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · July 29, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 29, 2025 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · June 5, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 5, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 5, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 5, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 5, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 9, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · May 9, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 9, 2023 · Corrected (the home has a date of correction)