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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
0E
1F
Potential for minimal harm
0A
0B
0C
September 4, 2025Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policies and the Centers for Disease Control and Prevention (CDC) related to enhanced-barrier precautions (EBP) and transmission-based precautions (TBP), it was determined 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 and control the development and transmission of communicable diseases for 2 of 39 sampled residents, Residents (R) 7, and R52.
July 12, 2024Standard inspection, Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to protect 1 (Resident #286) of 7 residents reviewed for abuse from resident-to-resident abuse. Specifically, the facility failed to protect Resident #286's right to be free from physical abuse perpetrated by Resident #284 on 08/19/2023.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure a pharmacy recommendation was addressed by the physician in a timely manner for 1 (Resident #34) of 5 residents reviewed for unnecessary medications. In addition, once the physician responded to the pharmacy recommendation, facility staff failed to immediately implement the physician's recommendation.
April 25, 2019Standard 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 observation, interview, and review of the facility's Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations, on 04/23/19, revealed dust accumulation on a fan used in the dish room and the ceiling above the production area. In addition, the dish machine temperatures were missing and not documented throughout the month of April 2019.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and review of facility's Policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (1) of twenty-three (23) sampled residents (Resident #4). Observation on 04/24/19 during the morning mealtime revealed Resident #4 was being assist by a SRNA who was standing next to and over top of the resident.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for three (3) of twenty two (22) sampled residents (Resident #8, Resident #49 and Resident 51). 1. Resident #8 had unwitnessed fall events in his/her room, during unassisted transfers, on 12/28/18 and 04/03/19. However, there was no documented evidence the Comprehensive Care Plan (CCP) was revised to include interventions related to the Root Cause of the fall events to prevent further falls of the same nature. 2. Per record review and interviews, Resident #49 sustained a fall, on 04/23/19 at the bedside during an unassisted transfer from the wheelchair to the bed. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for three (3) of twenty-two (22) sampled residents; Resident #8, Resident #49 and Resident #53. 1. Resident #8 was assessed by the facility to be at High Risk for falls and to require the limited assist of one (1) staff for transfers and ambulation, and extensive assist of two (2) for toileting. However, record review revealed on [DATE], the resident self-transferred from the bed to the recliner while alone in the bedroom without supervision. Resident #8 sustained a fall when sliding from the recliner seat to the floor. Additionally, per SRNA #7's Witness Statement, on [DATE], the resident stated he/she was trying to go to the restroom. [...]
- 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 record review, it was determined the facility failed to ensure that resident who enters the facility with an indwelling catheter or subsequently receives one was assessed for removal of the catheter as soon as possible and received appropriate treatment and services to prevent urinary tract infections and to restore continence, for one (1) of three (3) sampled residents observed for indwelling urinary catheter care out of twenty-two (22) sampled residents (Resident #51). Observation and interview with Resident #51, on 04/23/19 revealed the resident had an indwelling urinary catheter placed during a recent hospital stay related to excess fluid. [...]
Fire safety inspections
6 fire safety citations on file: 1 on September 4, 2025, 4 on July 12, 2024, 1 on April 25, 2019.
Every fire safety citation6 citations
- D
Ensure proper usage of power strips and extension cords.
K 920 · September 4, 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 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 12, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 25, 2019 · Corrected (the home has a date of correction)