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
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
15D
7E
0F
Potential for minimal harm
0A
0B
0C
June 23, 2026Complaint inspection · 3 citations
- J
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review, facility documentation review, observation of facility video, and staff interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure a resident with dementia that was dependent for personal care and mobility and had no physician orders for opioids was free from exposure to opioids. The resident was identified unresponsive to verbal or tactile stimulation with pinpoint pupils, and was transferred to the hospital where he/she was diagnosed with suspected opioid intoxication, received Narcan, and had two (2) laboratory tests that were positive for opioids, resulting in a finding of Jeopardy.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observations, record review, and facility documentation review for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation of resident property.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record review, and facility documentation review for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure staff followed accepted medication administration practices administration practices.
April 27, 2026Standard 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 a tour of the Dietary Department, observations, review of facility documentation, facility policy, and interviews the facility failed to ensure food temperatures were consistently obtained and logged prior to serving meals, refrigerator and freezer temperatures were consistently monitored and documented, dishwasher temperatures were consistently monitored and documented prior to washing dishes, sanitizer solution was consistently tested and logged prior to use to disinfect pots and pans and kitchen surfaces per manufacturer recommendations, and dietary staff wore a beard guard when preparing and serving food.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on clinical record reviews, review of the facility Infection Control Program, facility documents facility policy and interviews, the facility failed to provide education regarding the Covid Vaccine to staff members offering to provide the vaccine or inform where staff could obtain a Covid vaccination, and the facility failed to ensure documentation of screening residents for the eligibility to receive the Covid vaccine was completed, and residents and responsible parties received copies of Covid Vaccination educational materials prior to deciding to vaccinate or decline vaccination.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #3) reviewed for dining, the facility failed to ensure a dignified dining experience.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, facility documentation, review of facility policy and staff interviews for 1 of 4 residents (Resident #6) reviewed for abuse, the facility failed to keep the resident safe from physical and verbal abuse.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #21 and Resident# 117) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the state agency was updated subsequent to the residents' new psychiatric diagnoses.
- 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 clinical record review, observations, review of facility policy and interviews for 1 of 4 residents (Resident #1) reviewed for pressure ulcers, the facility failed to revise the resident plan of care regarding pressure ulcer interventions to prevent skin breakdown.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record review, observations, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #23) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure a resident was provided and or offered showers.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on clinical record review, observation, facility policy and interviews for 1 of 4 Residents (Resident #52) reviewed for nutrition, the facility failed to ensure a resident with a therapeutic diet was provided with food items to meet the needs of the resident.
October 18, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, facility documentation, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that staff provided the resident with the required assistance with bed mobility and as a result, Resident #1 fell out of bed and sustained a left femur (thigh bone) fracture.
July 11, 2024Standard inspection · 8 citations
- 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 of Resident Information, review of policy and interviews, the facility failed to inform residents of how to complete a grievance and ensure forms were accessible and available to residents and visitors.
- E
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 clinical record reviews, facility policy and interviews for 2 of 7 sampled residents for (Resident #13) who were reviewed for range of motion, the facility failed to ensure the comprehensive care plan was revised for a resident with identified with physical limitations of the hands and for (Resident # 98), the facility failed to develop a care plan to address the residents skin integrity to prevent further skin break down and for 1 of 2 residents reviewed for accidents for (Resident # 54), the facility failed to revise the resident's care plan timely post fall.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the clinical record, observations, and interview for 1 of 2 residents reviewed for pressure ulcers (Resident # 98), the facility failed to ensure staff consistently provided evidence of turning and repositioning the resident prior to the development of a pressure ulcer and the facility failed to ensure physician's orders were obtained for recommendations made by a consulting wound physician contributing to the pressure ulcer's further decline.
- E
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 reviews, observations, facility documentation, facility policy and interviews for 2 of 7 sampled residents (Resident #13 and Resident #97) reviewed for position and mobility, the facility failed to ensure further evaluation and timely treatment were implemented for resident(s) with newly identified limited mobility to maintain, improve or prevent further decline in range of motion and mobility over time and for 1 of 7 residents reviewed for contractures ( Resident # 86) the facility failed to ensure the application of braces and/or splints as per physician's orders.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on the tour of the Dietary Department, observations, policy review, and staff interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner and failed to ensure staff applied proper beard guards and failed to consistently labeled and stored food to reflect their age or shelf life.
- 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 clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #72) reviewed for missing property, the facility failed to ensure a report of a missing item was thoroughly investigated to conclude loss or theft and Observations of the facility environment, the facility failed to ensure a sanitary environment by ensuring a rusted medicine cabinet without doors was replaced and for 1 of 3 sampled residents (Resident #88) who was reviewed for environment, the facility failed to provide a clean, home like environment related to cleaning of a small appliance which was provided by the facility and based on observations and interviews for 3 of 4 shower rooms, the facility failed to provide a homelike, sanitary, and safe environment for the 3 of 4 showers.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, facility policy and interviews for 1 of 3 Residents (Resident #45), observed during medication administration, the facility failed to meet professional standards when staff borrowed(Resident # 202 's Lactulose medication to administer to Resident # 45 when the resident's medication was not available.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, facility policy, staff interviews for 1 of 1 resident reviewed for specialized treatment (Resident #48), the facility failed to consistently maintain the resident's communication log regarding the resident's status with the specialized treatment center.
March 22, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident had an elopement risk evaluation when the resident expressed intentions on leaving the facility.
December 20, 2021Standard inspection · 3 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, clinical record review, review of facility policy and interviews for 2 of 3 residents (Resident #28 and Resident #71) reviewed for pressure ulcers, the facility failed to follow physician orders for every 1 hour re-positioning for Resident #28 and failed to ensure a thorough assessment was completed when a pressure area was identified and failed to ensure a wound consultant's recommendations were reviewed and implemented in a timely manner for Resident #71.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review and staff interview for 1 of 12 residents reviewed for medication administration (Resident #92), the facility failed to ensure the medication cart and resident medications were secured.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, clinical record review and interview for 1 of 12 residents observed during medication administration (Resident #92) the facility failed to administer medication appropriately therefore causing the medication error rate to be above 5%.
Fire safety inspections
31 fire safety citations on file: 3 on April 27, 2026, 19 on July 11, 2024, 9 on December 20, 2021.
Every fire safety citation31 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 27, 2026 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · April 27, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 27, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · December 20, 2021 · Past noncompliance: already fixed when inspectors found it
- F
Provide a written emergency evacuation plan.
K 711 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 20, 2021 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 20, 2021 · Corrected (the home has a date of correction)