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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
22D
0E
1F
Potential for minimal harm
0A
0B
0C
July 22, 2026Complaint inspection · 2 citations
- 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 assist a dependent resident with nail care for 2 of 8 residents reviewed for ADLs (Activities of Daily Living). (Resident D and Resident J)
- 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 interview and record review, the facility failed to provide catheter care as ordered by the physician for 1 of 4 residents reviewed for catheter care. (Resident C)
March 6, 2026Standard inspection, Complaint 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, interview, and record review, the facility failed to ensure the stove hood was maintained in a clean sanitary manner. This deficiency had the potential to affected 58 of 58 residents who dine in the facility.
- 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 ensure a resident who received the wrong medication had a assessment completed, ongoing monitoring and vitals signs completed for 1 of 2 residents reviewed for quality of care (Resident B).
- D
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, interview and record review, the facility failed to implement a splint for a resident with bilateral hand contractures as ordered by the physician for 1 of 1 resident reviewed for Range Of Motion (Resident 51).
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interview and record review, the facility failed to adequately monitor and treat a resident's wandering behavior for 1 of 3 residents reviewed for dementia care and services. (Resident C)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's ordered medication was available for administration upon admission to the facility for 1 of 3 residents reviewed for pharmacy services. (Resident C)
July 28, 2025Complaint 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 interview and record review, the facility failed to prevent a resident from eloping (leaving the facility without others being aware or giving permission) through the resident's room window for 1 of 3 residents reviewed for elopement. (Resident B) The deficient practice was corrected on 7-23-25, prior to the start of the survey, and was therefore past noncompliance. [...]
March 14, 2025Standard inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents, including a confidential resident, were treated with dignity during care for 2 of 3 residents reviewed for dignity. (Resident 9 and Confidential Resident)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide a bath and/or shower upon request and as care planned for 1 of 1 resident reviewed for bathing. (Resident 6)
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review, the facility failed to provide routine dental care to residents when an inside source was not available for 1 of 3 residents reviewed for dental services. (Resident 2)
January 9, 2025Complaint inspection · 2 citations
- 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 ensure 2 of 2 residents diagnosed with Clostridium difficile infection (c-diff) were receiving care which included thorough and accurate assessments on a routine basis and the documentation of the assessments reflected the thorough assessments and resident status. (Residents B and C)
- 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 interview and record review, the facility failed to ensure 2 of 2 residents reviewed for urinary tract infections (UTI), received prompt treatment for complaints of dysuria (painful urination), urine culture and sensitivity reports be reviewed with the medical provider for accuracy related to the proper medications be ordered to treat the identified organisms, and their daily nursing assessments related to their diagnosis are thorough and accurate. (Resident B and D)
January 29, 2024Standard inspection, Complaint inspection · 11 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteA.) Based on observation, interview and record review the facility failed to adequate supervision during care and ensure two staff were providing care for a dependent resident resulting in the resident falling out of bed and sustaining 3 brain bleeds and 5 facial sutures (Resident B). B.) Based on observation, interview and record review the facility failed to have fall interventions of two assistive devices in place and failed to have a call light available for a resident who had sustained a fall with a fracture (Resident D). This affected 2 of 4 residents reviewed for accidents (Resident B and Resident D).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on interview, observation, and record review, the facility failed to complete self-administration assessment for a resident that self-administers nasal spray for 1 of 1 resident reviewed for self-administration. (Resident 37)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review the facility failed to provide fresh water daily for 2 of 5 residents reviewed for hydration (Resident D and Resident 45).
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review the facility failed to provide a resident with her choice and preference to when she went to bed for 1 of 2 residents reviewed for choices (Resident 56).
- 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 interview and observations, the facility failed to promote a clean environment for Resident 35 by having dried fecal matter on his toilet and a dried brown substance on his bed linens for 1 of 2 residents reviewed for clean environment.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and observation, the facility failed to submit a Discharge or Death Entry Minimum Data Set (MDS) assessment for Resident 48 and failed to accurately code specialized services for Resident 32 for 2 of 2 residents reviewed for MDS assessment accuracy.
- 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 a care plan for 1 of 2 residents reviewed for skin tears. (Resident 111)
- 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, observation, and record review, the facility failed to update a fall care plan for Resident 15 after his refusal to utilize careplanned fall interventions for 1 of 3 reviewed for fall care plans.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, observation, and record review, the facility failed to complete weekly nursing assessments per physician order for 3 of 3 residents reviewed for potential impaired skin integrity. (Resident 18, Resident 32, and Resident 38)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review, the facility failed to accurately complete weekly nursing assessments to reflect pressure areas for 2 of 2 residents reviewed for pressure areas (Resident 19 and Resident 32)
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's bed rail had safe dimensions. This affected 1 of 1 resident reviewed for accident hazards related to bed rail use. (Resident 21)
Fire safety inspections
22 fire safety citations on file: 5 on March 6, 2026, 10 on March 14, 2025, 7 on January 29, 2024.
Every fire safety citation22 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 6, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 6, 2026 · no revisit needed
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 6, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 6, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 6, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 14, 2025 · Waiver
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
K 791 · March 14, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 14, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 14, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 29, 2024 · Waiver
- E
Meet other general requirements.
K 100 · January 29, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 29, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · January 29, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 29, 2024 · Corrected (the home has a date of correction)