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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
2E
1F
Potential for minimal harm
0A
0B
0C
October 28, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, staff and caregiver interviews, and policy and procedures, the facility failed to ensure advance directives was followed for one resident (#10).
June 25, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, documentation, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#1) did not elope. The sample was 3. The deficient practice could result in resident harm.
March 28, 2025Standard inspection · 8 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure that prepared food were distributed to residents at a safe and appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure that a baseline care plan regarding urostomy care/treatment was developed for two of two sampled residents (#145, and #146). The deficient practice could result in goals and interventions not being evaluated, and available to the staff providing the care and treatment.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that anti-hypertensives were administered within parameters for two residents (Residents #14 and #27); and that, pain management medication were administered within parameters for one resident (Resident #27). The deficient practice could result in further instances of inaccurate pain management with opioid medication; and, inaccurate administration of blood pressure medication.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for 1 of 12 sampled residents (#37) accurately reflected their status regarding falls. The deficient practice could result in suboptimal care planning and effect the quality of care provided.
- 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 observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide indwelling (Foley) catheter care in accordance with professional standards of practice for one of one sampled resident (#146). This deficient practice could lead to indwelling foley catheter complications.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide ileostomy care in accordance with professional standards of practice for one of two sampled residents (#146). This deficient practice could lead to ileostomy skin complications.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to that ensure that policies regarding storing opened food and leftovers were followed. The deficient practice could result in the potential of bacterial growth in susceptible conditions.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and policy, the facility failed to ensure proper infection control practices were implemented to prevent development and transmission of communicable disease/infection for two of two sampled residents related to urostomy care for one resident (#145), and foley catheter care for one resident (#146). The deficient practice could result in transmission of infection. Findings Include: -Regarding Resident #145, PPE Donning/Doffing and hand hygiene: Resident #145 was admitted on [DATE] with diagnoses that included cerebral infarction, history of malignant neoplasm of bladder, and artificial openings of the urinary tract. Physician orders dated March 15, 2025, revealed an order for urostomy care two times a day. [...]
February 23, 2024Standard inspection · 1 citation
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure a copy of the notice of two out of two discharges for one resident (# 47) to a representative of the Office of the State Long-Term Care Ombudsman. The failure may result in residents not having the advocacy and support from the State Long-Term Ombudsman during the discharge process.
November 23, 2022Standard inspection · 0 citations
Fire safety inspections
6 fire safety citations on file: 2 on March 28, 2025, 2 on February 23, 2024, 2 on November 23, 2022.
Every fire safety citation6 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · March 28, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 28, 2025 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · February 23, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · February 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 23, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 23, 2022 · Corrected (the home has a date of correction)