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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
1E
2F
Potential for minimal harm
0A
0B
0C
July 3, 2026Standard inspection · 4 citations
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed receiving the medication Ertapenem (an antibiotic prescribed to treat serious bacterial infections) intravenously (IV), Resident ID #82; and for 1 of 1 resident reviewed receiving the medication Bumetanide (a diuretic prescribed to increase the excretion of urine to help relieve fluid retention), Resident ID #61.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that medical records for each resident are complete and accurately documented for 2 of 2 resident reviewed who experienced significant medication errors, Resident ID #s 82 and 61.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections related to contact precautions (an infection control intervention designed to reduce the transmission of diseases and infections spread by direct and indirect physical contact, requiring staff to wear a gown and gloves before entering a resident's room) for 2 of 3 residents observed on contact precautions, Resident ID #s 87 and 91.
- D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on record review and staff interview, the facility failed to provide mandatory in-service training relative to the Quality Assurance and Performance Improvement (QAPI) program that outlines and informs staff of the elements and goals of the program for 3 of 10 staff reviewed; Staff C, D, and E. Additionally the facility failed to provide required in-service training for nurse aides, to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year, including dementia management training and resident abuse prevention for 1 of 5 nurse aides reviewed, Staff F.
March 3, 2026Complaint inspection · 1 citation
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 3 residents reviewed relative to physician's orders for laboratory testing, Resident ID #s 1 and 2.
March 19, 2025Standard 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 prepare, serve and distribute food in accordance with professional standards for food service safety relative to the main kitchen. Additionally, the facility failed to ensure a certified food protection manager was available during the preparation of all meals.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to respect the residents' right to personal privacy for 1 of 1 resident observed relative to his/her weight, Resident ID #10, and for 1 of 1 resident observed during a wound dressing change, Resident ID #52.
- 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 residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders relative obtaining laboratory test panels for 1 of 3 residents receiving Atorvastatin (a medication prescribed to treat high cholesterol, without proper monitoring Atorvastatin can lead to liver and kidney damage), Resident ID #52.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice in accordance with physician orders and the comprehensive person-centered care plan, for 1 of 1 resident reviewed receiving antibiotics via a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications), Resident ID #125.
- 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 record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, relative to a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications) for 1 of 1 resident reviewed with a PICC, Resident ID #125.
April 11, 2024Standard inspection · 6 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 and 2 of 2 kitchenettes observed.
- 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 residents receive treatment and care in accordance with professional standards of practice, for 1 of 3 residents reviewed for the use of insulin, Resident ID #65.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents observed for wound care, Resident ID #32.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident receives appropriate assistive devices to prevent accidents for 1 of 5 residents reviewed for falls, Resident ID #44.
- 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 provide appropriate treatment and services for 1 of 1 resident reviewed with a suprapubic catheter (a flexible rubber or plastic tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #1.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 3 residents reviewed for antibiotic use, Resident ID #s 124 and 129.
September 1, 2023Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident was free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1.
Fire safety inspections
5 fire safety citations on file: 1 on March 19, 2025, 4 on April 11, 2024.
Every fire safety citation5 citations
- D
Provide properly protected cooking facilities.
K 324 · March 19, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 11, 2024 · Corrected (the home has a date of correction)