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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
1E
0F
Potential for minimal harm
0A
0B
0C
July 20, 2026Complaint inspection · 3 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the comprehensive care plan and physician ordered toileting schedule for one (#4) out of four sampled. As a result, Resident #4 experienced overnight incontinence without timely care, and scheduled toileting was not consistently implemented or documented. Findings Include: During an observation and interview on 7/20/26 at 7:15 a.m., Resident #4 was seated in a wheelchair, well groomed and dressed in street clothing. During the interview, the resident became tearful, appeared stressed, and reported having a bad night. Resident #4 stated she was incontinent during the night and staff did not provide incontinent care until she was assisted with getting dressed for the day. [...]
- 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 interviews, the facility failed to ensure that effective supervision and fall prevention interventions were implemented to prevent an avoidable fall with injury for one (Resident #6) out of three residents sampled. Review of Resident #6's Resident Information Record showed she was originally admitted on [DATE] and readmitted on [DATE]. Her diagnoses included: periprosthetic fracture around an internal prosthetic left knee joint (subsequent encounter) dated 04/30/2026; unspecified fracture of the upper end of the left humerus (subsequent encounter with routine healing) dated 02/20/2026; Type 2 Diabetes Mellitus with diabetic polyneuropathy dated 02/20/2026; fracture of the left shoulder girdle (subsequent encounter with routine healing) dated 02/20/2026; need for assistance with personal care dated 02/20/2026; [...]
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on record review and interviews, the facility failed to ensure ostomy care was provided and documented according to the physician's orders for one (Resident #5) out of three residents reviewed for ostomy care. This failure resulted in the inability to determine whether the resident received required ostomy care and hygiene support.
June 6, 2024Standard inspection · 4 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen, walk-in cooler, walk-in freezer, reach-in freezer, and stock room (Photographic evidence obtained).
- 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 residents received care and services for PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 of 3 reviewed residents with a PICC access device, Resident #104 (Photographic evidence obtained).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 of 3 reviewed residents with PICC (Peripherally Inserted Central Catheter) line, Resident #104.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper PPE (Personal Protective Equipment) while providing high-contact care for 1 of 3 residents reviewed for transmission-based precautions, Resident #341, and failed to ensure staff performed hand hygiene between residents during meal tray delivery to help prevent the possible development and transmission of communicable disease and infections.
March 17, 2022Standard inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and interviews, the facility failed to maintain an environment that promotes dignity and privacy for one (Resident #87) of thirty five sampled residents.
- 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 ensure the care plan was implemented related to preventing skin impairment for one (Resident #25) of three in-house acquired pressure injury residents, and 2. facility did not ensure to implement the plan of care for Resident # 37 regarding placement of an ankle brace and podus boots.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure injury prevention measures for one (Resident #25) of three residents sampled for in-house acquired pressure ulcers.
January 8, 2021Standard inspection · 4 citations
- 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 observations, staff interviews, and medical record review the facility failed to ensure care plan interventions were implemented for one (#98) of 54 sampled residents as evidenced by Resident #98 not wearing an abductor wedge pillow between her legs as ordered and care planned. Findings Included: A record review for Resident #98 revealed admission diagnoses to include fracture of unspecified part of neck of Left Femur, subsequent encounter for closed fracture with routine healing, weakness, and difficulty walking. A review of active physician orders dated 12/05/2020 revealed an order to apply abductor wedge between legs when in wheelchair for LE (lower extremity) positioning every shift and dated 12/02/2020 Hip Range of Motion (ROM) precautions every shift. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observation, and interviews the facility did not ensure appropriate physician's orders were obtained and implemented for nephrostomy tubes for one (#226) of 54 sampled residents.
- 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, interview and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure an indwelling urinary catheter bag and tubing was maintained off the floor to prevent potential infection for one resident #(243) during two of two observations, of 5 residents with catheters.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interviews and record review the facility failed to ensure laboratory services were provided in a timely manner in accordance with physician orders for one (#112) of 54 sampled residents related to a lipid panel.
Fire safety inspections
5 fire safety citations on file: 1 on June 6, 2024, 4 on January 8, 2021.
Every fire safety citation5 citations
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 8, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2021 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 8, 2021 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 8, 2021 · Corrected (the home has a date of correction)