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
0G
0H
0I
Potential for more than minimal harm
14D
3E
0F
Potential for minimal harm
0A
0B
3C
February 27, 2026Standard inspection · 3 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 35 sampled residents. (Residents 23, 158)
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 35 sampled residents. (Resident 13)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions (EBP) and the use of personal protective equipment (PPE) to prevent the spread of infection for one of 35 sampled residents. (Resident 1)
January 21, 2026Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, staff interview, and a review of facility documentation, it was determined that the facility failed to implement safety interventions to prevent falls for one of four sampled residents. (Resident 3)
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on resident and staff interviews, review of facility policy, and clinical record review, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted catheter (a thin plastic tube inserted into a vein using a needle) in accordance with professional standards of practice for one of two residents. (Resident 4)
March 12, 2025Standard inspection, Complaint inspection · 8 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 and staff interview it was determined that the facility failed to store food under sanitary conditions in the kitchen.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 32 sampled residents. (Resident 3)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to provide services to improve activities of daily living (ADLs) for one of 32 sampled residents. (Resident 14)
- 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 clinical record review, observation, and resident interview, it was determined that the facility failed to implement interventions to prevent a decline in range of motion for one of 32 sampled residents. (Resident 103)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 32 sampled residents. (Resident 99)
- 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 clinical record review and policy review, it was determined that the facility failed to assess residents who were incontinent of bladder to determine the cause of the incontinence or if normal bladder function could be restored for two of 32 sampled residents. (Residents 9 and 87)
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, it was determined that the facility failed to dispose of trash and refuse properly.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post accurate and current nurse staffing information.
January 28, 2025Complaint inspection · 1 citation
- C
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 facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to notify the resident's representative of a 30 day advanced notice of discharge and failed to notify the resident and the resident representative(s) of hospital transfer(s), including the reasons for the moves, Ombudsman information, and how to file an appeal, in writing for four of four sampled residents who had an impending discharge from the facility or who were transferred to the hospital. (Residents 1, 2, 3, 4)
February 22, 2024Standard inspection · 6 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review, observation and resident and staff interview, it was determined that the facility failed to ensure that a resident had the call bell accessible for one of 33 sampled residents. (Resident 139)
- 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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 33 sampled residents. (Resident 39, 42)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that appropriate assistance with eating was provided to one of four sampled residents who required assistance with activities of daily living, including eating. (Resident 139)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for four of 33 sampled residents. (Resident 22, 64, 116, 121)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on policy review, clinical record review, observation, and interview, it was determined that the facility failed to ensure that staff provided services consistent with professional standards of practice for one of three sampled dialysis residents. (Resident 147)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to post accurate and current nurse staffing information.
Fire safety inspections
12 fire safety citations on file: 1 on March 12, 2025, 11 on March 10, 2023.
Every fire safety citation12 citations
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 10, 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 · March 10, 2023 · 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 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Provide properly sized and located linen or trash receptacles.
K 754 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · March 10, 2023 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for medical documentation.
E 23 · March 10, 2023 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · March 10, 2023 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · March 10, 2023 · Corrected (the home has a date of correction)