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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
3E
0F
Potential for minimal harm
0A
2B
0C
April 24, 2026Standard inspection · 6 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, observations, clinical record review, facility documentation, and facility policy, the facility failed to maintain a safe environment for residents in two distinct areas, resulting in the findings of Immediate Jeopardy. First, the facility failed to conduct adequate monitoring of hot water temperatures and to communicate and act upon documented temperatures exceeding 120 F, resulting in water temperatures ranging from 126.3 F to 145.4 F in 44 of 64 resident rooms on the second and third floors. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #16) reviewed for accidents, the facility failed to report an injury of unknown origin (bruise above the left eyebrow) to the state agency within established timeframes.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #16) reviewed for accidents, the facility failed to thoroughly investigate an injury of unknown origin.
- 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, facility policy review and interview for 1 of 8 sampled residents (Resident #16) reviewed for accidents, the facility failed to update/ revise the resident's care plan for behaviors.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #117) reviewed for Activities of Daily Living (ADL), the facility failed to ensure Resident #117 was ambulated per physician's orders.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, review of the clinical record, and review of facility policy for 1 of 1 resident (Resident #85) reviewed for blood glucose monitoring, the facility failed to maintain appropriate infection control practices during blood glucose monitoring.
July 18, 2024Complaint inspection · 2 citations
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of (3) three residents (Resident #1), reviewed for the discharge process, the facility failed to notify the homecare agency timely of a discharge delaying start of care.
- 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 the one (1) of three (3) residents reviewed for admission plan of care, (Resident #1), the facility failed to follow physician's orders regarding a medication.
June 11, 2024Complaint inspection · 1 citation
- 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, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for care planning, the facility failed to ensure care plan was comprehensive.
May 10, 2024Standard inspection, Complaint inspection · 11 citations
- E
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 clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #87) reviewed for nutrition, the facility failed to notify the physician and resident representative regarding a significant weight loss.
- E
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 review of the clinical record, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident #81 and #160) receiving anticoagulant medication, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring that should accompany the use of an anticoagulant.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #87) reviewed for nutrition, the facility failed to ensure the dietician assessed the resident for weight loss timely and failed to obtain the resident's monthly weight in accordance to facility policy.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, review of facility policy and interviews for one sampled resident (Resident #166) observed self-administering medications, the facility failed to ensure the resident was assessed for self-administration of medications.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #126), the facility failed to ensure the physician's order and the resident's signed Advance Directives were congruent.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, review of clinical records, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #42) reviewed for positioning and range of motion, the facility failed to ensure a physician's order was in place for the use of splints and for one sampled resident (Resident #213) who had orders for a compounded medication, the facility failed to ensure expired medication was not administered to the resident.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #213) who had physician orders for a compounded medication, the facility failed to ensure the medicaion was administered as ordered. Resident #213's diagnoses included protein calorie malnutrition, gastro-esophageal reflux disease (GERD) without esophagitis, and end stage renal disease. The admission MDS assessment dated [DATE] identified Resident #213 had intact cognition and was dependent for eating, oral hygiene, toileting, showering/bathing, and dressing. The Resident Care Plan dated 3/20/24 identified the resident has a nutritional problem or related to advanced age, therapeutic diet, mechanically altered diet, fluid restriction, food allergy, tube feeding supplementation diet, poor by mouth intake, increased nutritional needs. [...]
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, facility policy and interviews for one of three sampled medication rooms the facility failed to store medications appropriately.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of facility documentation, review of facility policy, and interviews, for 2 of 3 residents (Resident #42 and Resident #230) reviewed for infection surveillance, the facility failed to identify and maintain records of residents with known MDRO colonization and failed to appropriately cohort residents with a known MDRO colonization.
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on clinical record reviews, and interviews for three sampled residents (Residents #25, #104, and #170) reviewed for resident assessments, the facility failed to ensure quarterly MDS assessments were completed and submitted within prescribed timing parameters.
- B
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of personnel files, review of facility policy, and interviews for two of three sampled nurse aides (NA #1 and #3) the facility failed to complete annual performance evaluations.
September 27, 2023Complaint inspection · 2 citations
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record reviews, facility documentation, policy, and interviews for one of three sampled residents (Resident #1) who were a new admission and received a medication to treat a low thyroid level, Levothyroxine, the facility failed to transcribe the medication on admission to ensure the resident was free of a significant medication error.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on clinical record reviews, facility documentation, and interviews for one of three sampled residents (Resident #1) who were a new admission, the facility failed to implement the physician's order and obtain laboratory blood work.
November 24, 2021Standard inspection · 3 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #538) reviewed for Advance Directives, the facility failed to ensure the physician's order reflected the resident written choice.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record reviews, and interviews for one sampled resident (Resident #539) who was a recent admission and exhibited behavioral symptoms, the facility failed to transcribe a physician's order from the discharging facility to include the indication of use directive for an as needed medication.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #77) reviewed for respiratory care, the facility failed to provide necessary respiratory care consistent with professional practice.
Fire safety inspections
23 fire safety citations on file: 11 on April 24, 2026, 7 on May 10, 2024, 5 on November 24, 2021.
Every fire safety citation23 citations
- E
Have exits that are accessible at all times.
K 271 · April 24, 2026 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · April 24, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 24, 2026 · Corrected (the home has a date of correction)
- D
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 24, 2026 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 24, 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 24, 2026 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 24, 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 24, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Establish staff and initial training requirements.
E 37 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
K 700 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · May 10, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 24, 2021 · 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 · November 24, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 24, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 24, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 24, 2021 · Corrected (the home has a date of correction)