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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
13E
0F
Potential for minimal harm
0A
1B
0C
December 19, 2025Standard inspection · 5 citations
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on review of selected facility policies, clinical records, and staff interviews, the facility failed to show documented clinical justification for the administration of psychoactive medications for two residents out of five sampled residents for unnecessary medication prescribing practices (Residents 5 and 18).
- 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, select policy review, and staff interviews, it was determined the facility failed to ensure the resident environment remained free from potential accident hazards for one resident (Resident 10) of 24 sampled residents when medications were left accessible at the bedside without documented clinical assessment for safety or authorization to self-administer.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on a review of clinical records and select facility policy, and staff interviews, it was determined the facility failed to monitor a resident's weight and timely identify significant weight loss and assure timely assessment of a resident's nutrition status to timely develop and implement nutritional approaches addressing significant weight and notify a resident's attending physician and responsible party of significant weight loss for one resident out of four residents sampled for nutrition (Resident 9).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure the availability of required emergency dialysis supplies and failed to provide person-centered care related to hemodialysis for one resident out of two residents reviewed who received hemodialysis (Resident 88).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that necessary behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents reviewed for behavioral health needs (Resident 94).
February 28, 2025Standard inspection · 3 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of select facility policy and clinical records, and staff interview it was determined the facility failed to timely identify significant weight loss and monitor resident's weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions for two of 24 residents sampled. (Residents 72 and 27)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on a review of select facility policies and clinical records and staff interview, it was determined the facility failed to administer pain medication as prescribed by the physician on an as needed basis for one of 24 residents reviewed. (Resident 10).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to implement procedures to ensure accurate documentation of the disposition of controlled medications upon discharge for one (1) of three (3) discharged residents reviewed (Resident 109).
May 23, 2024Complaint inspection · 4 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, clinical record review and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, respect, and quality of life of seven residents out of 17 sampled (Resident 3, 4, 7, 9, 11,12, 16).
- 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 observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.
- 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 interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs and prescribed medication therapy for one resident out of 17 sampled residents (Resident 13).
- 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 select facility policy, observation, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration/use by dates for one of 15 residents (Resident 15) and failed to properly label medication in one of five medication carts (Center Cart).
April 5, 2024Standard inspection, Complaint inspection · 13 citations
- E
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on a review of clinical records, select facility policy CMS guidance and facility documentation, and resident, resident representative, and staff interviews, it was determined that the facility failed to ensure that resident Medicare beneficiaries were only disenrolled from Medicare health plans with the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding for four out of the 23 residents sampled (Residents 82, 95, 168, and 269).
- 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, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.
- 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 clinical record review and staff interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs for one resident (Resident 82) and prescribed medication therapy for three residents out of 23 sampled residents (Resident 48, 80, and 53).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate consistent monitoring and thorough assessment of one resident displaying constipation (Resident 116) and by failing to follow physician orders for bowel protocol prescribed for two residents out of 23 sampled (Residents 36 and 48) to promote normal bowel activity to the extent practicable.
- E
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 review of clinical records, and staff interview, it was determined that the facility failed to implement individualized approaches to restore normal bladder function to the extent possible and provide maintenance incontinence care for two out of 23 sampled residents (Resident 36 and 64).
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on a review of clinical records and select facility policy, and a staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one out of the 23 residents sampled (Resident 23).
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of select facility policy and controlled drug shift count records, observations, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three of five medication carts (Center, North, and West).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations of the resident pantry areas, review of select facility policy, and staff interview, it was determined that the facility failed to maintain a sanitary environment and acceptable practices for the storage and service of food to prevent the potential for microbial growth in foods and conditions, which increased the risk of food-borne illness in two of two resident pantry areas.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, a review of clinical records and interviews with staff it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one of one resident sampled with communication needs/deficit (Resident 318).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a history of trauma for one out of 23 residents reviewed (Resident 23).
- 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, a review of select facility policy, and staff interview, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication on one of three medication carts observed (Center medication cart - Resident 40).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection during the medication administration for one out of two residents observed (Resident 170) and one of three medication administration carts (center hall) sampled.
- B
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 clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for five residents out of 23 residents sampled with facility inititiated transfers (Residents 29, 46, 64, 80, and 269).
November 8, 2023Complaint inspection · 4 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to provide person-centered care for diabetes management and medication administration and blood glucose monitoring for one resident out of four sampled (Resident A1).
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, clinical record review and staff and resident interview it was determined that the facility failed to provide drinks consistent with resident needs and preferences for four out of seven residents sampled (Residents B1, B2, B3, and A1).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations and resident and staff interviews it was determined that the facility failed to accommodate residents' need for ready access to the call bell system to request staff assistance for one resident (Resident B1) and timely accommodation of the residents' needs for assistance in accordance with the residents' needs out of seven sampled. (B1 and B2).
- D
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on a review of clinical records and facility documentation and staff interview, it was determined the facility failed to provide information orally and in writing regarding changes in Medicare eligibility and coverage in a language and format the resident understood for one of four reviewed (Resident CR1).
Fire safety inspections
14 fire safety citations on file: 5 on December 19, 2025, 6 on February 28, 2025, 3 on April 5, 2024.
Every fire safety citation14 citations
- E
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 · December 19, 2025 · 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 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 19, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 28, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 28, 2025 · Corrected (the home has a date of correction)
- E
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 · April 5, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 5, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the use of electrical equipment.
K 919 · April 5, 2024 · Corrected (the home has a date of correction)