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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
14D
1E
0F
Potential for minimal harm
0A
0B
0C
November 21, 2025Standard inspection · 6 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident had their predetermined advance directive preference of Do Not Resuscitate (DNR) when she was changed to a full code status upon admission for 1 of 3 residents reviewed for advanced directives (Resident 69).
- 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 record review and interview, the facility failed to ensure that a resident's code status matched the comprehensive care plan for 1 of 5 residents reviewed for advance directives (Resident 12).
- 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 ensure a medication was withheld based upon the physician ordered parameter set for that medication. This deficient practice had the potential to effect 1 of 5 residents reviewed for unnecessary medications, (Resident 12).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's fall interventions were followed to prevent the potential for accidents when she was left alone in the bathroom and transferred with only one staff member on three separate occasions for 1 of 5 residents reviewed for falls (Resident 32).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to continue nutritional and pharmaceutical supplements for a malnourished resident who was not yet at her goal of achieving and maintaining an ideal body weight resulting in continued weight loss for 1 of 2 residents reviewed for weight loss and nutrition (Resident 46).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective individualized person-centered care for a resident who exhibiting dementia-related behaviors, including repeated attempts to undress, restlessness, and signs of discomfort for 1 of 3 resident reviewed for dementia care (Resident 46).
August 7, 2024Standard inspection · 5 citations
- 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 record review, the facility failed to ensure proper handwashing for 2 of 2 dining observations. This had the potential to affect 53 of 53 residents who ate meals from the kitchen.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure resolutions to the concerns voiced by the Resident Council were communicated back to the Resident Council for 1 of 3 months of Resident Council minutes reviewed (Resident 35).
- 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 interview and record review, the facility failed to ensure care plan meetings were conducted at least quarterly for 3 of 24 resident's reviewed for care plan meetings (Residents 34, 23, and 1).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a weight loss of greater than 5% in a 30-day period, had been addressed at the time the weight loss occurred for 1 of 1 residents reviewed for nutrition (Resident 34).
- 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 ensure medications were labeled properly for 1 of 2 medication carts observed for medication storage (Residents 254, 255, and 18).
July 17, 2023Standard inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteA. Based on interview, observation, and record review, the facility failed to ensure that staff used the assistance of two people when providing care and staff had the proper knowledge of the use of a low air loss mattress to prevent a resident's fall out of bed, which resulted in harm when the resident obtained a fractured femur (thigh bone) that required surgery for 1 of 14 residents reviewed for accidents (Resident 27). B. Based on interview, observation, and record review, the facility failed to ensure hot water temperatures were maintained within safe range for 3 of 14 residents reviewed for accidents (Residents 11, 40, and 26).
- 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 that contracted staff completed a resident assessment and vital signs in privacy for 1 of 1 resident randomly observed (Resident 32).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a privacy curtain was installed for 1 of 1 resident reviewed for privacy (Resident 29).
- 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, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a catheter which is inserted into the bladder and remains in to drain urine) tubing was kept from contact with the floor for 1 of 2 residents reviewed for urinary catheters (Resident 198).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a pharmacy recommendation was addressed timely for 1 of 5 residents reviewed for unnecessary medications (Resident 5).
Fire safety inspections
4 fire safety citations on file: 1 on November 21, 2025, 3 on August 7, 2024.
Every fire safety citation4 citations
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 7, 2024 · Corrected (the home has a date of correction)
- B
Install corridor and hallway doors that block smoke.
K 363 · August 7, 2024 · Corrected (the home has a date of correction)
- B
Ensure proper usage of power strips and extension cords.
K 920 · August 7, 2024 · Corrected (the home has a date of correction)