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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
2E
0F
Potential for minimal harm
0A
0B
0C
May 14, 2026Complaint inspection · 1 citation
- J
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 provide supervision to prevent a cognitively impaired resident with a history of exit seeking behavior from leaving the facility property without staff knowledge for 1 of 3 residents reviewed. (Resident B)B. Based on observation, interview, and record review, the facility failed to ensure the secured unit courtyard gate was locked for 2 of 3 observations. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 5/8/26 at approximately 9:30 a.m. when the facility failed to provide supervision to prevent a cognitively impaired resident with a history of exit seeking behavior from leaving the facility property for an unknown amount of time without staff knowledge. [...]
July 15, 2025Complaint inspection · 1 citation
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical restraints for 1 of 4 residents reviewed for restraints. A restraint was applied by unlicensed personnel, there was no physician's order, consent, or documentation for release of the restraint. (Resident B, CNA 3)
April 25, 2025Standard inspection · 5 citations
- E
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, interview, and record review, the facility failed to provide a homelike environment free of damage, disrepair, and odor of urine for 1 of 2 secured units and 5 of 7 resident rooms reviewed for environment. (Reflections 2 Unit, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])
- D
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 interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 53)
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 53)
- 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 ensure care plan fall interventions were in place for a resident who was at risk for falls for 1 of 4 residents reviewed for accidents. (Resident 107)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to provide care per the plan of care for 1 of 5 residents reviewed for unnecessary medications. Insulin was not held per physician's orders. (Resident 107)
April 3, 2025Complaint inspection · 1 citation
- J
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 provide supervision to prevent a cognitively impaired resident, who had an appointed guardian and history of exit seeking, from exiting the facility without staff knowledge for 1 of 3 residents reviewed for elopements. This deficient practice resulted in the resident being located by local law enforcement 1.8 miles away. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 3/29/25 at approximately 9:45 p.m., when the facility failed to prevent a cognitively impaired resident from leaving the facility without staff knowledge. The Area [NAME] President and Regional Nurse were notified of the Immediate Jeopardy on 4/2/25 at 12:20 p.m. [...]
January 27, 2025Complaint inspection · 2 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed practical nurse observed medication administration for a resident who did not self administer medications for 1 of 1 resident observed during a random observation. (Resident B)
- 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 ensure staff accurately documented wound care treatments for 1 of 3 residents reviewed for documentation. (Resident C)
October 18, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. (LPN 1, Resident C)
June 24, 2024Standard inspection · 6 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a self medication administration assessment was complete for residents with medications left at bedside for 1 of 1 random observations. (Resident 80)
- D
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 interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 2 of 3 residents reviewed for hospitalization. (Resident 54 and Resident 64)
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 2 of 3 residents reviewed for hospitalization. (Resident 54 and Resident 64)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to have an ongoing communication with the dialysis center regarding dialysis care while at dialysis for 1 of 1 residents reviewed for dialysis care. (Resident 63)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered with adequate indications for use for 1 of 5 residents reviewed for unnecessary medications. Medications were administered outside of physician order parameters. (Resident 88)
- 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 ensure staff documented neurological assessments for 1 of 1 residents reviewed for falls. (Resident 105)
April 2, 2024Complaint 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 fall when staff did not use a gait belt (an assistive device used by staff that wraps around a resident to assist the resident and staff with a transfer) to transfer a resident who was dependent on staff for transfers for 1 of 3 residents reviewed for falls. (Resident B)
July 24, 2023Standard inspection · 3 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, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 3 of 3 kitchen observations. Food was stored beneath a water line on which water had condensed and the kitchen walk-in freezer door and walk-in refrigerator seal gasket was in disrepair.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the residents status for 2 of 3 residents reviewed for resident assessment. (Resident 34, Resident 36)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented new weight loss interventions for a resident with an assessed weight loss for 1 of 7 residents reviewed for nutrition. (Resident 3)
Fire safety inspections
32 fire safety citations on file: 18 on April 25, 2025, 7 on June 24, 2024, 7 on July 24, 2023.
Every fire safety citation32 citations
- F
Implement emergency and standby power systems.
E 41 · April 25, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · April 25, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 25, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · April 25, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 25, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 25, 2025 · 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 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 25, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 25, 2025 · 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 25, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 25, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · April 25, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 25, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · April 25, 2025 · Waiver
- 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 25, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 25, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 25, 2025 · 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 · April 25, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · June 24, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · June 24, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 24, 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 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 24, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 24, 2024 · Corrected (the home has a date of correction)
- B
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 24, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 24, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 24, 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 · July 24, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 24, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 24, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements that are deficient.
K 300 · July 24, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements that are deficient.
K 500 · July 24, 2023 · Corrected (the home has a date of correction)