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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
2E
0F
Potential for minimal harm
0A
0B
0C
March 13, 2026Standard inspection · 4 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to hold ordered blood pressure medication when a resident's blood pressure was outside prescribed parameters for 1 of 6 residents reviewed (Resident 9) and failed to properly assess a Resident (Resident 96) for their ability to properly manage their own eye drops before they were kept at the bedside for 1 of 24 residents reviewed for medications at bedside.
- 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 and interview, the facility failed to refrigerate a medication until opened and failed to date nasal sprays and eye ointment when opened for 1 or 2 medication carts reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure proper infection control practices were in place for 2 of 24 residents reviewed for infection control when a resident with a central line (a long, flexible tube inserted into a major vein in the neck, chest, or groin, extending to just above the heart) and a resident with a suprapubic urinary catheter were not in Enhanced Barrier Precautions (EBP) (an infection control strategy designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) (Residents 2 and 85) and the dressing for the central line was not changed per policy for 1 of 1 resident reviewed for central lines (Resident 2).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure essential kitchen equipment and associated systems were maintained in proper working order to prevent the potential contamination for 2 of 2 observations.
March 7, 2025Standard inspection · 5 citations
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on interview and record review, the facility failed to ensure Medical Providers entered their visit assessments, summaries, and/or progress notes into the resident's medical records timely for facility staff access. Theis deficient practice had the potential to effect of 6 of 13 residents records reviewed, (Residents 1, 9, 12, 14, 16, and 99).
- 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 develop and implement a person-centered care plan related to recurrent Urinary Tract Infections (UTI) for a resident (Resident 4) who had seven UTI's in a 12-month period for 1 of 16 residents reviewed for care plans.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate/effective interventions were in place to prevent the development of new open pressure and failed to ensure accurate documentation was detailed in the medical records for 2 of 2 residents reviewed for pressure ulcers (Residents 16 and 24).
- 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 (Resident 99) who had a history of falls, had an environment free from the potential for accidents when the rubber threshold of the shower was unattached and loose on the floor for 1 of 3 residents reviewed for accidents.
- 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 and interview, the facility failed to date medications when opened for 1 of 3 medication carts reviewed.
May 24, 2024Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, and interview, the facility failed to ensure showers were provided for 1 of 1 residents reviewed for bathing preference (Resident B).
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure a nurse aide was competent to safely transfer a resident while using a mechanical lift for 2 of 4 residents reviewed for mechanical lifts (Resident B).
February 2, 2024Standard inspection, Complaint inspection · 6 citations
- 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 implement complete, person centered care plans for 4 of 4 residents reviewed for advance directive care plans (Residents 19, 26, 33 and 146).
- 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, and record review, the facility failed to ensure a resident was wearing weather appropriate clothing when leaving the facility for 1 of 2 residents reviewed for dignity (Resident 104).
- 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 ensure a resident, (Resident E) received appropriate and timely treatment after a fall with fracture for 1 of 4 residents reviewed for quality of care.
- 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, the facility failed to ensure a Foley catheter bag (part of a urinary drainage system) was kept off the floor for a resident with a history of urinary tract infections (UTI) for 1 of 3 residents observed for closed urinary drainage system (Resident 39).
- 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 record review, observation and interview, the facility failed to dispose of a controlled medication after it had expired for a resident (Resident 17) for 1 of 2 medication storage rooms observed.
- D
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 appropriately assist a resident with eating for 1 or 2 residents observed for assistance with eating (Resident 6) and failed to complete correct hand hygiene during dining services for 2 of 2 dining observations (Resident 6 and 16).
Fire safety inspections
3 fire safety citations on file: 1 on March 13, 2026, 1 on March 7, 2025, 1 on February 2, 2024.
Every fire safety citation3 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 13, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 7, 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 · February 2, 2024 · Corrected (the home has a date of correction)