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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
0E
0F
Potential for minimal harm
0A
1B
0C
December 18, 2025Standard inspection · 2 citations
- 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, and staff interviews, the facility failed to cover food as staff carried it down the halls for 2 out of 2 meals observed. The facility reported a census of 35 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, clinical record review, facility policy review, and staff interviews, the facility failed to implement Enhanced Barrier Precautions (EBP) during high contact care in an effort to reduce exposure to multidrug-resistant organisms (MDRO) for 2 out of 5 residents reviewed (Resident #16 and Resident # 23). The facility reported a census of 35 residents.
February 3, 2025Standard inspection · 0 citations
March 28, 2024Standard inspection, Complaint inspection · 4 citations
- J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, staff interviews, family interviews, and policy review the facility failed to complete skin assessments and provide treatments per physician's orders for 2 of 4 residents reviewed (Residents #14 and #89) with pressure ulcers. Both residents admitted to the facility with skin concerns and the facility failed to document the skin issues until days after their admission. Due to the lack of assessment and intervention the residents' skin injuries went from mild to serious impairment with exposed fat tissue and/or bone. This resulted in an immediate jeopardy situation. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 3/21/24 at 4:44 PM. The IJ began on 1/25/24. Facility staff removed the Immediate Jeopardy on 3/22/24 at 11:03 AM by completing the following: 3/22/24 a. [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on observation, clinical record review, staff interviews and facility policy review the facility failed to provide a Bed Hold Notice to 3 out of 3 residents reviewed for hospitalization (Residents #7, #9, and #14).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, and record review, the facility failed to administer insulin as directed by the Physician Order. The nurse failed to prime an insulin pen for 2 of 2 doses for 1 resident observed during medication administration (Resident #25).
- B
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 observation, clinical record review, staff interview and facility policy review the facility failed to notify the Ombudsman's office three out of three times one resident went to the hospital (Resident #7).
September 18, 2023Complaint inspection · 3 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and staff interviews, the facility failed to notify the physician of abnormal findings on an X-ray report that indicated treatment was required for the resident's condition, the resident's condition declined and required hospitalization within 48 hours of the findings on the report, for 1 of 11 resident records reviewed (Resident #14). Findings Include: The 4/8/23 Minimum Data Set (MDS) Assessment Tool revealed Resident #14 had diagnoses that included diabetes and septicemia, and the resident able to make himself understood and understood others. A Chest X-ray report dated 5/1/23 revealed the resident had right lower lobe pneumonia with effusion (presence of fluid). A physician order dated 5/2/23 directed staff to administer 750 milligrams (mg) of Levaquin (a strong antibiotic) oral daily for 5 days to treat the pneumonia. [...]
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to prevent misappropriation of a resident's narcotic analgesic medication, for 1 of 7 resident's reviewed with narcotic medication orders (Resident #11). The facility reported a census of 35 residents. Findings Include: The 4/5/23 Minimum Data Set (MDS) Assessment Tool revealed Resident #11 had diagnoses that included non-Alzheimer's dementia, other fracture, anxiety and acute respiratory failure with hypoxia (low oxygen level in the blood), severe cognitive impairment without symptoms of delirium present, always able to make self understood and understand others, received analgesic medications administered on a scheduled and as needed basis for pain during the 5 days that preceded the assessment. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, and staff, pharmacy and resident interviews, the facility failed to order and maintain a supply of narcotic analgesic medications that were prescribed by the physician and required to treat a resident's condition, failed to communicate with their pharmacy as required when the medication supply on hand was low, and failed to follow appropriate professional standards of practice related to narcotic medication management. The failure of the facility resulted in the resident's hospitalization for severe pain, after staff exhausted the resident's supply and 13 tablets from the facility's emergency medication system, without any communication with their pharmacy to reorder the medication, for 1 of 7 resident records reviewed for narcotic medication orders (Resident #13). Findings Include: [...]
Fire safety inspections
8 fire safety citations on file: 1 on December 18, 2025, 3 on February 3, 2025, 4 on March 28, 2024.
Every fire safety citation8 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 18, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · February 3, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 3, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 3, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 28, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 28, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 28, 2024 · Corrected (the home has a date of correction)