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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
20D
9E
0F
Potential for minimal harm
0A
0B
0C
April 15, 2026Standard inspection, Complaint inspection · 8 citations
- E
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 the dignity of residents was maintained and respected for 3 of 4 resident reviewed for dignity and 16 of 134 residents reviewed in resident council. (Residents' B, E, F, G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z).
- E
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 follow-up with resolutions to concerns brought up in resident council meetings were reported back to the resident council members. This had the potential to effect 16 of 134 residents that attended resident council meeting. (Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z)
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were able to file grievances anonymously for 16 of 134 residents reviewed during resident council. (Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z)
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meal services were provided timely for 19 of 134 residents that eat food served from the kitchen. (Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, Z, BB, CC and DD)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to timely document meal consumption for 1 of 3 residents reviewed for nutrition (Resident B).
- 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 address a resident lying in another resident's bed, as care planned, for 1 of 2 residents reviewed for dementia care. (Resident 4)
- 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 medication was available for administration for 1 of 2 residents reviewed for hospitalization (Resident E).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review, the facility failed to timely complete a physician's ordered STAT (immediate) laboratory test as ordered, for 1 of 2 residents reviewed for laboratory services. (Resident 15)
March 25, 2025Standard inspection, Complaint inspection · 7 citations
- G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff (Qualified Medication Aide 6 and Certified Nurse Aide 2) notified the nurse on duty of a resident experiencing a fall (Resident D) and timely notify the resident's physician of a fall with injury, resulting in Resident D experiencing moderately strong pain and a delay in the treatment of a left humerus fracture, for 1 of 2 residents reviewed for falls, and to timely inform a physician of a significant change in a lab value for 1 of 2 residents reviewed for hospitalization (Resident B). This deficient practice was corrected on 2/19/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: [...]
- G
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 D) who had fallen the night of 1/21/25, was assessed by a licensed nurse and the licensed nurse was made aware of the fall incident by the facility staff (Qualified Medication Aide 6 and Certified Nurse Aide 2), who had assisted the resident back to bed, and ensure the resident had continued monitoring afterwards. The resident experienced moderately strong pain, had skin impairments, and was later hospitalized and identified with a fractured humerus at the hospital for 1 of 3 residents reviewed for falls. This deficient practice was corrected on 2/12/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: [...]
- E
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 ensure a resident's hair was shampooed at least weekly, properly positioned a resident to reduce the risk of skin shearing, and to provide timely incontinence care and not utilizing double briefing for 4 of 11 residents reviewed for Activities of Daily Living (ADL) care. (Resident D, Resident G, Resident L and Resident 20)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed when gloves were changed when performing incontinent care for 1 of 8 residents reviewed for activities of daily living, failed to maintain infection control while providing catheter care for 1 of 1 resident reviewed for catheter care, failed to ensure staff performed hand hygiene during coffee service, and to ensure medication carts were cleaned after touched by residents for 3 of 3 residents randomly observed. (Resident E, Resident F, Resident G, Resident H and Resident L)
- 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 follow a resident's choices for 1 of 1 resident reviewed for choices. (Resident 30)
- 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 accurately document urinary output as ordered for a resident with an indwelling catheter for 1 of 1 resident reviewed for catheters. (Resident E)
- 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 the availability of medications to administer as ordered for 1 of 1 resident reviewed for care planning and 1 of 5 residents reviewed for unnecessary medications. (Resident 47 and Resident 182)
January 3, 2025Complaint inspection · 5 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to administer a synthetic opioid pain patch in accordance with the physician order, the manufacturer's specifications, or accepted professional standards to prevent a significant medication error for 1 of 3 residents reviewed for medication regimen. (Resident C) This deficient practice resulted in the resident having two opioid pain patches applied simultaneously, the resident experienced a significant change in consciousness that required emergent administration of an opioid overdose medication, and hospitalization. This deficient practice was corrected on 12/31/24, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to timely notify a resident representative of a fall for 1 of 3 residents reviewed for falls. (Resident B)
- 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 care planned fall interventions were implemented for 1 of 3 residents reviewed for falls. (Resident F)
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review, the facility failed to document a resident's behaviors, implement behavior interventions that were put in place to address the resident's behaviors, and evaluate the effectiveness of behavior interventions for 1 of 3 residents reviewed for abuse. (Resident H)
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to ensure the environment was free from strong urine odors for 1 of 3 residents reviewed for environment (Resident J).
October 28, 2024Complaint inspection · 1 citation
- 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 an accurate system of records for controlled medications for 1 of 3 residents reviewed for hospice services. (Resident C)
April 26, 2024Complaint inspection · 1 citation
- 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 ensure nail trimming and hand hygiene was provided for 3 of 3 residents reviewed for upper extremity devices. (Residents' C, D and F)
January 30, 2024Standard inspection, Complaint inspection · 10 citations
- E
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 and interview, the facility failed to ensure a clean, comfortable, and homelike environment for Residents F and G, and the potential to affect all 37 residents that reside on the memory care unit (MCU).
- E
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: monitor and assess a resident's bruising, per policy, for 1 of 7 residents reviewed for dementia care (Resident 92); accurately monitor fluid consumptions for a resident that was ordered to be on a 1,500 milliliter (ml) fluid restriction for 1 of 5 residents reviewed for unnecessary medications and monitor a resident's output every shift per the plan of care for 1 of 1 residents reviewed for hospitalization (Resident 35 and Resident 127); and administer insulin and to obtain daily weights as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for skin condition (Resident P and 33).
- E
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 adequate monitoring and supervision and implement behavior care plan interventions for 8 of 37 cognitively impaired residents on the memory care unit. (Residents 4, 29, 58, 63, 64, 89, 92, and 100)
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to report resident to resident altercations that resulting in pain and bruising for 2 of 37 residents on the memory care unit. (Residents 89 and 92)
- 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 ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary assistance needed for showering at least twice weekly as preference by a resident for 1 of 4 residents reviewed for ADLs. (Resident Q)
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent a stage III pressure ulcer from developing on a resident with a moderate risk for developing a pressure ulcer for 1 of 1 residents reviewed for pressure ulcers. (Resident R)
- 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 fall interventions were in place for 2 of 5 residents reviewed for accidents. (Resident L and P)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened liquids at bedside, as ordered by the physician, for 1 of 1 resident reviewed for hydration (Resident F)
- 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 there were staff available to access medications in the emergency drug kit (EDK) regarding antianxiety medication for a resident experiencing anxiety for 1 of 5 residents reviewed for mood/behavior. (Resident E)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 by not testing a resident with signs and/or symptoms of COVID- 19 timely for 1 of 1 residents reviewed during a random observation for respiratory care. (Resident Q).
Fire safety inspections
29 fire safety citations on file: 17 on April 15, 2026, 4 on March 25, 2025, 8 on January 30, 2024.
Every fire safety citation29 citations
- F
Conduct testing and exercise requirements.
E 39 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 15, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 15, 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 · April 15, 2026 · 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 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
K 524 · April 15, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2025 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · March 25, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 25, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 25, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · January 30, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 30, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 30, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 30, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 30, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 30, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 30, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · January 30, 2024 · Corrected (the home has a date of correction)