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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
9D
6E
3F
Potential for minimal harm
0A
0B
0C
December 19, 2025Standard inspection · 4 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 observation, interview, and record review, the facility failed to maintain the kitchen in a manner that prevents food borne illness. This applies to all 49 residents receiving dietary services.
- F
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, interview, and record review, the facility failed to safely store hazardous chemicals and carbon dioxide cylinders in the kitchen and failed to maintain a clothes dryer in a safe manner. This applies to all 49 residents receiving dietary services.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to renew an as needed hospice order prior to administering the medication, failed to apply compression treatments as ordered, and failed to ensure a resident with a fungal rash was kept dry and clean. This applies to 3 of 4 (R7, R1, R34) residents reviewed for quality of care in a sample of 18.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to reconcile controlled substances. This applies to 3 of 3 residents (R7, R47, and R59) reviewed for narcotics in a sample of 18.
July 30, 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 observation, interview, and record review, the facility failed to ensure a resident was transferred safely with a mechanical lift. This applies to 1 resident (R1) reviewed for safety in a sample of 3. The past non-compliance occurred between 7/10/2025 and 7/18/2025.
September 20, 2024Standard inspection · 7 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 observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and wear hair restraints in the facility kitchen. This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, facility failed to provide showers and nail care to residents who need assistance with ADLs (activities of daily living). This applies to 4 of 4 residents (R26, R151, R301 and R302) reviewed for ADLs in a sample of 23.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, facility failed to follow infection control precautions. This applies to 6 residents (R2, R21, R33, R37, R46, and R301) reviewed for infection control in a sample of 23.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to implement an antimicrobial stewardship program, providing antibiotic use protocols, and monitoring to prevent antibiotic resistance. This applies to 8 of 8 residents (R1, R7, R32, R42, R46, R303, R353, R354) reviewed for antibiotics in a sample of 23.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for residents with a contagious gastrointestinal infection and Foley catheter. This applies to 2 of 2 residents (R46 and R2) reviewed for privacy in the sample 23.
- D
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 properly transfer resident and failed to properly dispose of a sharp disposable razor. This applies to 2 out of 2 residents (R42, R356) reviewed for accidents in a sample of 23.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for over the counter medications and to have medications stored in resident rooms. This applies to 2 of 2 residents (R29 and R354) reviewed for medications in the sample of 23.
October 5, 2023Standard inspection · 6 citations
- E
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 provide assistance with ADLs (Activities of Daily Living) for residents assessed as needing staff assistance for ADL (Activities of Daily Living) care and grooming. This applies to 4 of 5 residents (R1, R4, R17, and R187) reviewed for ADL care.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify person-centered, non-pharmacological approaches for residents receiving psychotropic medications. The facility also failed to identify resident-specific behaviors to monitor the response/effectiveness of psychotropic medications. This applies to 4 of 5 residents (R1, R25, R29, and R187) reviewed for unnecessary medications in a sample of 15.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on interview and record review, the facility failed to plan and serve menus which provided variety and the minimum servings of grains as per facility policy. This applies to 4 of 4 residents (R4, R15, R18, and R25) reviewed for menu planning in a sample of 15.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure R4's room entryway light was working properly and provided adequate lighting, and R9's special pressure reduction mattress was functioning correctly. This applies to 2 of 2 (R4, R9 ) reviewed for homelike environment in a sample of 15.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper technique when administering a nasal spray to a resident. This applies to 1 of 5 residents (R4) reviewed for medication administration.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident with a diagnosis of dysphagia received pudding thick liquids per the doctor's order. This applies to 1 of 4 residents (R18) reviewed for food/nutrition in a sample of 15.
September 14, 2023Complaint inspection · 1 citation
- G
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 follow safe transfer practices when utilizing a mechanical lift. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3. This failure resulted in R1 incurring 2 lacerations to her head requiring staples to both lacerations.
Fire safety inspections
15 fire safety citations on file: 7 on December 19, 2025, 4 on September 20, 2024, 4 on October 5, 2023.
Every fire safety citation15 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 19, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 19, 2025 · 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 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 19, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 20, 2024 · 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 · September 20, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 20, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 20, 2024 · 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 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 5, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 5, 2023 · Corrected (the home has a date of correction)