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
1J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
4E
3F
Potential for minimal harm
0A
0B
0C
April 23, 2026Standard inspection · 2 citations
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and staff interview, the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff B, C, and D.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 1 resident reviewed with a wanderguard (a wearable tag, often in a bracelet or anklet form, used to prevent individuals with cognitive impairments from eloping or wandering from a secured area), Resident ID #113.
November 28, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to keep residents free from abuse for 1 of 3 residents reviewed relative to a resident-to-resident incident, Resident ID #1.
June 4, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed, Resident ID #1.
February 20, 2025Standard inspection · 2 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety relative to the main kitchen, 3 of 3 kitchenettes and 4 of 4 [NAME] House kitchens observed.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following a physician's order for nutritional supplements, for 2 of 2 residents reviewed, Resident ID #s 6 and 54, and for 1 of 1 resident reviewed for blood pressure monitoring who is prescribed furosemide, (a medication used to reduce fluid), Resident ID #54.
January 13, 2025Complaint inspection · 2 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, staff and resident interview it has been determined that the facility failed to ensure that a newly admitted resident received adequate supervision to prevent an elopement for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #1.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident related the elopement of Resident ID #1. This failure resulted in an Immediate Jeopardy for F 689.
November 25, 2024Complaint inspection · 1 citation
- J
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents receive and consume food in the appropriate form for 1 of 3 residents reviewed for a modified diet of pureed texture, Resident ID #1.
October 3, 2024Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and #2, resulting in a skin tear for Resident ID #2.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 1 resident reviewed with a skin tear, Resident ID #2.
March 6, 2024Standard inspection, Complaint inspection · 5 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 3 of 3 kitchenettes, and 4 of 4 [NAME] House kitchens.
- 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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident receives incontinence care per the resident's plan of care for 1 of 3 residents reviewed for incontinence care, Resident ID #196.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of the clinical reference ranges in a timely manner for 1 of 2 residents reviewed relative to labratory services, Resident ID #89.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive and consume fluids in the appropriate form for 1 of 1 resident observed with a dietary order for nectar thickened fluids, Resident ID #67.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide required in-service training, including dementia management training for 4 of 7 staff members reviewed, Staff D, J, K, and L.
January 22, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order specific to as needed (PRN) medication for agitation for 1 of 6 residents reviewed, Resident ID #1.
December 5, 2023Complaint inspection · 3 citations
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a physician reviewed the resident's total program of care, including medications and treatments, at each visit, for 1 of 1 resident reviewed, Resident ID #1.
- E
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 staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 1 resident reviewed with an order for psychotropic medication ordered as needed (PRN) without a stop date, Resident ID #1.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed for skin conditions, Resident ID #'s 1 and 3. Additionally, for 1 of 1 residents reviewed with orders for a consultation with an outside specialist relative to the diagnosis of kidney failure, Resident ID #1.
Fire safety inspections
8 fire safety citations on file: 2 on April 23, 2026, 6 on March 6, 2024.
Every fire safety citation8 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 23, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 23, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 6, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 6, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 6, 2024 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · March 6, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 6, 2024 · Corrected (the home has a date of correction)
- C
Establish policies and procedures including evacuation.
E 20 · March 6, 2024 · Corrected (the home has a date of correction)