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
0G
0H
0I
Potential for more than minimal harm
4D
13E
2F
Potential for minimal harm
0A
0B
0C
August 28, 2025Standard inspection · 2 citations
- 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 observation, record review and interview, the facility failed to ensure meals were served according to the planned written menu to meet the nutritional needs of the residents for one of one meal observed.
- 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 facility policy review, the facility failed to ensure the ice machine was maintained in a sanitary manner; expired food items were promptly removed or discarded on or before the expiration or use by date, that dietary staff washed their hands between dirty and clean equipment, and hot food items were maintained at required temperature for one of one meal observed.
February 5, 2025Complaint inspection · 1 citation
- 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 record review and interview, the facility failed to ensure staff followed the Care Plan of a resident who was at risk for falls, as evidenced by intervention of a fall mat not being on the floor beside resident's bed to prevent injury for 1 (Resident # 1) of 3 sampled residents.
October 1, 2024Complaint 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 properly transfer a resident using a mechanical lift and failed to investigate and educate to prevent possible injury for one (Resident #2) sampled resident who was transferred via mechanical lift.
May 23, 2024Standard inspection · 10 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, record review, and interview, the facility failed to ensure food items were discarded by their use by date; food items were stored and served in a manner to prevent cross contamination; and hair covering for the face and head were worn at all times in 1 of 1 kitchen.
- E
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 record review and interview, the facility failed to ensure residents individualize plan of care was revised to reflect the current needs of the resident and updated to include falls for 02 (Resident #06, #31) of 02 sample mix resident, and to include half side rail use for 01 (Resident #06) of 01 sample mix residents.
- E
Provide appropriate foot care.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for 1 (Resident #68) of 1 sampled resident.
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures in one of one sampled resident (Resident #8).
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from potential accidents from half side rail use for 1 (Resident #06) and failed to ensure bed side rails were properly padded for a resident with a seizure disorder for 1 (Resident #06) of 1 sampled resident, and failed to ensure a wheelchair was left unlocked to prevent an injury for 1 (Resident #294) of 1 sample mix resident.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rail assessments were performed before the use of bed rails for 1 (Resident #06) of 1 sampled resident reviewed for accidents.
- E
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 policy review, the facility failed to ensure controlled medications were stored in a permanently affixed container in the medication room.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure 5 sampled residents who have a physician's order for a pureed diet received food which was smooth, lump free consistency to minimize the threat of choking or other complications.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's preferences or allergies for a diet was implemented for 1 (Resident #79) of 1 sampled resident.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteThe facility failed to ensure a comprehensive, accurate assessment of the resident's side rail use was completed quarterly for 01 (Resident #06) of 01 sample mix residents.
April 7, 2023Standard 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, and interview, the facility failed to ensure the kitchen floor was maintained in clean, sanitary condition for food preparation to prevent the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen; the refrigerator temperature and dairy products stored in the refrigerator were maintained at 41 degrees Fahrenheit or below; food items stored in the freezer were sealed or covered to prevent the potential for cross contamination or freezer burn, employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen and the ice machine was maintained in clean condition to prevent the potential contamination of residents' beverages. These failed practices had the potential to affect 79 residents (total census: [...]
- 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 ensure residents feet were kept clean for 1 (Resident #28) of 8 (Residents #16, #17, #21, #28, #40, #57, #66 and #130) sampled residents who required assistance or were dependent on staff for activities of daily living (ADL) and/or bathing.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation of the 8:00 AM and 12:00 PM medication passes on [DATE], record review, and interview, the facility failed to maintain a medication error rate of less than 5% to prevent potential complications for 2 (Residents #1 and #18) of 3 (Residents #1, #3 and #18) residents observed during the medication pass, resulting in medication errors. Medication errors were made by 2 Licensed Practical Nurses (LPN #1 and LPN #2) who were observed administering medications in the facility. The medication error rate was 5.88% based on the observation of 34 medication opportunities and 2 errors detected.
- 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 observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets and 17 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 04/06/23.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident #40) of 1 sampled resident received a trapeze bar to assist with positioning as ordered by the Physician.
Fire safety inspections
9 fire safety citations on file: 3 on August 28, 2025, 4 on May 23, 2024, 2 on April 7, 2023.
Every fire safety citation9 citations
- F
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 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 7, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 7, 2023 · Corrected (the home has a date of correction)