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
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
12D
2E
0F
Potential for minimal harm
0A
0B
0C
April 2, 2026Complaint inspection · 3 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, review of the Emergency Medical Service (EMS) Patient Care Report, review of hospital records, review of information from the National Institute of Health, review of information from the Centers for Disease Control, facility policy and interview, the facility failed to ensure Resident #195's vision/eye needs were comprehensively assessed, treated, and monitored to timely identify an acute change in condition and prevent a complication requiring hospitalization. This affected one resident (#195) of three residents reviewed for a change of condition. The facility census was 194. Actual harm occurred on 02/15/26 when Resident #195 was transferred to the hospital due to increased pain to her left eye, purulent drainage and loss of vision. The resident was diagnosed with a corneal ulcer and infection resulting in hospitalization. [...]
- 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, record review and review of the facility policy the facility failed to ensure Resident #195's urinary tract infection was treated properly with antibiotics per physician orders. This affected one resident (Resident #195) out of three residents reviewed for antibiotic administration. The facility census was 194.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for Resident #65. This affected one resident (#65) of three residents observed for infection control. The facility census was 194.
May 22, 2024Standard inspection · 3 citations · risk-based survey (a shorter visit CMS gives only to higher performing homes)
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wrote4.) During observation and interview with R154 on 5/21/24 at approximately 5:05pm, R154 stated he goes to dialysis (a treatment for people whose kidneys are failing). R154 stated, Yes, three times [a week] Monday, Wednesday, Friday. When asked about his dialysis access site, R154 showed the surveyor his right upper arm. The site was covered with a dressing and secured with a tape. R154 stated he would get weighed at the dialysis unit. When asked if staff had been checking his vital signs when he returned from dialysis, R154 stated, No. R154 explained that staff checked him in the morning before but not after his dialysis treatment. Review of R154's Medical Diagnosis in Point Click Care (PCC, healthcare software and electronic health record) included end stage renal disease (kidney failure) and dependence on renal dialysis. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and interview, the facility failed to maintain dignity and respect at all times for Resident #62 and R448 by ensuring urinary drainage bags were covered. This affected two residents (#62 and R448) of two residents reviewed for dignity. The facility census was 188.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a comprehensive care plan, physician orders, and interventions of monitoring and evaluation was in place for Resident #144's hand restraint. This affected one resident (Resident #144) of two residents reviewed for restraint use. The total census was 188.
May 10, 2023Standard inspection · 6 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interview, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures for enhanced barrier precautions and failed to ensure the multi-use glucometer blood testing (BGT) machine was disinfected and sanitized effectively to prevent the potential for cross-contamination of blood borne pathogens. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Residents #14, and #72. This affected two residents (#14 and #72) of 197 residents reviewed for call light placement. The facility census was 197.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure wound care was completed as ordered. This finding affected one (Resident #143) of three residents reviewed for wounds.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #165's pressure relieving foam boots were implemented as ordered. This finding affected one (Resident #165) of two residents reviewed for pressure wounds. The facility census was 197.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #193 was provided adequate supervision during care to prevent a fall. This finding affected one (Resident #193) of two residents reviewed for falls.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). This finding affected two (Residents #75 and #125) of six residents observed for medication administration. A total of 26 medications were administered with two errors for a medication error rate of 7.69%.
December 5, 2019Standard inspection · 3 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 record review and interview the facility failed to ensure advance directives for Resident #64 were accurately and consistently noted throughout the resident's medical record. This affected one resident (#64) of one resident reviewed for advance directives.
- 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 ensure Resident #72, who had a urinary (Foley) catheter had timely orders, assessments and documentation of care appropriate for the management of the catheter. This affected one resident (#72) of one resident reviewed for urinary catheter care.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, record review and interview the facility failed to provide Resident #171 with a comfortable home like environment. This affected one resident (#171) of 79 residents who resided on the second floor unit.
Fire safety inspections
32 fire safety citations on file: 5 on May 22, 2024, 7 on May 10, 2023, 20 on December 5, 2019.
Every fire safety citation32 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 22, 2024 · 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 22, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 10, 2023 · 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 10, 2023 · 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 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 10, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
K 132 · December 5, 2019 · Waiver
- F
Have an enclosure around a vertical opening shaft.
K 311 · December 5, 2019 · Waiver
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 5, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 5, 2019 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · December 5, 2019 · deficient, provider has
- C
Conduct testing and exercise requirements.
E 39 · December 5, 2019 · deficient, provider has