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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
14D
2E
2F
Potential for minimal harm
0A
0B
0C
January 27, 2026Standard 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 wroteA. Based on observation and interview, the facility failed to ensure food was prepared and served under safe and sanitary conditions regarding food handling and hand washing. This deficient practice had the potential to impact 100 of 102 residents who received their meals from the kitchen. B. Based on observation and interviews, the facility failed to store, prepare, and distribute food under safe sanitary conditions regarding the removal of dented food cans. This deficiency had the potential to impact 100 of 102 residents who received their meals from the kitchen.
- D
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 provide daily grooming assistance for nail care for 2 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident 43, Resident 12)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to follow physician orders regarding the administration of blood pressure medication according to ordered parameters for 1 of 5 residents reviewed for unnecessary medications (Resident 3).
- D
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 provide adequate supervision to prevent repeated falls for a cognitively impaired resident for 1 of 4 residents reviewed for accidents. (Resident 58)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize infection control prevention and control practices for residents requiring enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for infection control. (Resident 12)
December 17, 2024Standard inspection, Complaint inspection · 6 citations
- G
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 services for bed mobility were provided with two staff members present to a dependent resident who required total assistance of two staff for bed mobility for 1 of 3 residents reviewed for falls. (Resident 99) This deficient practice resulted in Resident 99 falling from the bed and sustaining a fracture left knee joint.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's call light was within reach for 1 of 3 residents reviewed for environment. (Resident 39)
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a homelike environment by failing to repair a damaged wall for 1 of 3 residents reviewed for environment. (Resident 103)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide daily grooming assistance for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident 112)
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange dental appointments for a resident who misplaced or lost their dentures for 1 of 1 resident reviewed for dental services. (Resident B)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection prevention and control strategies for transmission-based precautions were followed for 2 of 2 residents reviewed for COVID-19 isolation precautions. (Resident 35 and 67)
May 6, 2024Complaint inspection · 3 citations
- G
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 urinary catheter outputs were monitored and documented for 3 of 3 residents reviewed for urinary catheters (Residents D, H, and J), resulting in Resident D being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to administer insulins as ordered and scheduled for 2 of 3 residents reviewed for insulin administration (Resident B and C).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received supervision per physician order and facility policy during the administration of a nebulized medication for 1 of 1 resident during a random observation. (Resident G)
December 4, 2023Standard inspection · 5 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) had sufficient time to perform IP responsibilities by requiring the full-time DON to assume the (at minimum) part-time IP role with a facility census of 96 residents. This deficient practice had the potential to affect 96 of 96 residents who resided at the facility.
- E
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on interview and record review, the facility failed to ensure the activity director completed the required education to meet the qualifications for an activity director.
- D
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 implement care plan interventions to reduce the risk of falls for 1 of 3 residents reviewed for accidents. (Resident 95)
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident did not receive an antipsychotic without an indication of use for 1 of 5 residents reviewed for unnecessary medications (Resident 31).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, facility failed to ensure residents received accurate, up-to-date information on currently available vaccinations for 3 or 5 residents reviewed for immunizations (Residents 7, 22, 82).
October 12, 2023Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely administration of insulin per physician orders for 4 of 4 residents reviewed for insulin administration (Resident B, C, D and E).
Fire safety inspections
13 fire safety citations on file: 4 on January 27, 2026, 4 on December 17, 2024, 5 on December 4, 2023.
Every fire safety citation13 citations
- F
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
K 524 · January 27, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 27, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 27, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 27, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 17, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · December 17, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 17, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 17, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · December 4, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 4, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 4, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 4, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 4, 2023 · Corrected (the home has a date of correction)