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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
0E
0F
Potential for minimal harm
0A
0B
0C
December 4, 2025Standard inspection · 6 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure a properly executed DNR (Do Not Resuscitate) Order for 3 of 3 sampled residents, as evidenced by incomplete yellow copy DNR Order forms for Residents #134, #116, and #62.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record, review and interviews, the facility failed to provide care and services for the treatment and prevention of wounds for 5 of 38 sampled residents as evidenced by failure to follow physician orders for the treatment of a wound for Residents #182 and #36, failure to ensure Resident #184 had treatment for a rash, and failure to complete weekly skin assessments for Residents #182, #27, and #134.
- 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 provide appropriate care and positioning equipment for 2 of 3 sampled residents as evidenced by failure to provide properly fitting wheelchair leg rests for Resident #118 and failure to provide a hand/towel roll for hand contractures to Resident #12.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assess residents for safe smoking for 2 of 3 sampled residents reviewed for smoking, Residents #38 and #170.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to ensure appropriate care and services for oxygen use for 1 of 3 sampled residents as evidenced by the lack of oxygen order and oxygen saturation assessment for Resident #124.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on competency review, observation, and interview, the facility failed to ensure infection control practices during the medication pass observation with 1 of 6 licensed nurses (Staff C, Licensed Practical Nurse), as evidenced by the failure to dispose of gloves after use, failure to ensure hand hygiene with glove use, failure to properly disinfect a glucometer (device that measures the resident's blood sugar level), and failure to properly dispose of the used lancet. The medication pass observation was for Resident #38.
June 6, 2024Standard inspection · 5 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accessibility of the call bell for 1 of 1 sampled resident, Resident #99, observed needing assistance and unable to call staff.
- 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, interview, and policy review, the facility failed to ensure the anchoring of indwelling urinary catheter tubing for 2 of 3 sampled residents, one of whom had a history of urinary tract infections (UTIs), Residents #34 and #204.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure competent nurse staff for 2 of 7 sampled residents observed during the medication administration observation. Staff C, Licensed Practical Nurse (LPN), failed to follow the facility's process related to the administration and documentation of insulin for Resident #49; and Staff B, Licensed Practical Nurse failed to use proper technique during a nasal spray administration for Resident #74.
- D
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 record review, interview, and policy review, the facility failed to implement pharmacy recommendations approved by the physician for 1 of 5 sampled residents, Resident #38.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation and policy review, the facility failed to prepare pureed food with the correct texture. This had the potential to affect 16 of 165 current residents who had a physician ordered pureed diet.
January 29, 2024Complaint inspection · 1 citation
- 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 policy review, observation, interview and record review, the facility failed to ensure proper perineal care to residents with a history of and current Urinary Tract Infection (UTI) for 1 of 3 sampled residents observed during perineal care, Resident #3.
March 24, 2023Standard inspection · 3 citations
- J
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 a secure environment to prevent an elopement for a resident with dementia and documented wandering and exit-seeking behavior, for 1 of 3 sampled residents reviewed for elopement, Resident #134. The resident eloped from the facility on 03/07/23 between 2:20 PM and 2:30 PM and was returned to the facility by a 'passerby' after being located in the community near the facility at 2:30 PM. It was unknown by facility staff and management precisely where Resident #134 was located. Upon being returned to the facility, Resident #134 was placed in the Memory Care Unit (secured unit). Upon assessment after being returned to the facility, Resident #134 was not harmed and showed no signs of distress. [...]
- 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, record review, and policy review, the facility failed to act on the voiced grievance for 1 of 3 sampled residents who utilize the sit-to-stand transfer device. Resident #49 voiced her concerns to Staff J, Certified Nursing Assistant (CNA), who failed to act upon the voiced grievance.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review, the facility failed to initiate a care plan for newly identified behaviors for 1 of 26 sampled residents, whose care plans were reviewed, Resident #134.
Fire safety inspections
7 fire safety citations on file: 2 on December 4, 2025, 1 on June 6, 2024, 4 on March 24, 2023.
Every fire safety citation7 citations
- F
Provide properly protected cooking facilities.
K 324 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 24, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 24, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 24, 2023 · 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 24, 2023 · Corrected (the home has a date of correction)