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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
5D
0E
0F
Potential for minimal harm
0A
0B
0C
January 9, 2026Complaint inspection · 2 citations
- G
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 and record review the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for 1 (R1) of 3 residents reviewed for indwelling catheters in the sample of 4. This failure resulted in R1 being sent to a local hospital emergency department, flown to an out of state hospital and admitted with diagnoses including Sepsis and Complicated UTI.Findings Include:R1's admission Record documented that R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Unspecified Dementia, aortic valve stenosis, dysphagia, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit, and pain. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review the facility failed to notify the physician of a change in condition timely for 1 (R1) of 3 residents reviewed for change in condition in the sample of 4. Findings Include:R1's admission Record documented that R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Unspecified Dementia, aortic valve stenosis, dysphagia, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit, and pain. R1's MDS (Minimum Data Set) quarterly assessment with an Assessment Reference Date of December 12, 2025, documented a Brief Interview for Mental Status (BIMS) score of 06 indicating R1 had severe cognitive impairment. [...]
November 14, 2024Standard inspection · 2 citations
- 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 fall prevention interventions for 1 of 5 residents (R35) reviewed for falls in a sample of 24.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal vaccinations for 3 of 5 residents (R20, R31, R29) reviewed for immunizations in a sample of 24.
October 5, 2023Standard inspection · 0 citations
July 13, 2022Standard inspection · 2 citations
- D
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 implement fall prevention interventions to prevent falls for two (R2 and R11) of three residents at risk for and reviewed for falls in the sample of twenty three.
- 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, record review, and interview, the facility failed to provide aseptic catheter care for one (R31) of one resident at risk for and reviewed for UTI (Urinary Tract Infections) in the sample of twenty-three.
Fire safety inspections
14 fire safety citations on file: 7 on November 14, 2024, 2 on October 5, 2023, 5 on July 13, 2022.
Every fire safety citation14 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 14, 2024 · 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 · November 14, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 14, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · October 5, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 5, 2023 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 13, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 13, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 13, 2022 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 13, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 13, 2022 · Corrected (the home has a date of correction)