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
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
17D
5E
0F
Potential for minimal harm
0A
0B
0C
July 2, 2026Standard inspection · 5 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital and failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), for five of six residents reviewed (Residents R2, R5, R43, R55, and R94).
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of 30 residents reviewed (Residents R10, R39, R42, R55, and R79).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for one of six residents reviewed (Resident R8).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical records, facility policy and documents, and staff interviews, it was determined that the facility failed to perform a transfer in a safe manner for one of 30 residents reviewed (Resident R62).
- 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 review of facility policy, manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to ensure medications were properly dated when opened in one of two medication rooms reviewed (First Floor Main Medication Room).
January 23, 2026Complaint inspection · 1 citation
- 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 review of facility policy and documents, observations, and resident and staff interviews, it was determined that the facility failed to have adequate housekeeping staff to maintain clean and sanitary hallways on two of two floors observed and clean and sanitary resident rooms on one of two floors observed.
July 18, 2025Standard inspection · 5 citations
- E
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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of four medication carts reviewed and one of two medication rooms reviewed (first floor C-wing and second floor C-wing medication carts and second floor medication room). Review of facility policy entitled Medication Storage and Handling dated [DATE], indicated Medications will be monitored. to assure that they are not expired. Review of facility policy entitled Administering Medications dated [DATE], indicated When opening a multi-dose container, the date opened is recorded on the container. Review of Active liquid protein label indicated three-month shelf life from date open. Review of manufacturer's guidelines revealed that an open pen of Lispro Insulin must be used within 28 days after opening or be discarded. [...]
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer, and failed to have complete documentation related to a transfer for three of 20 residents reviewed (Residents R3, R31, and R105).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and change/date oxygen tubing according to physician's orders for two of two residents reviewed for respiratory services (Residents R45 and R58).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R12).
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to assure the call bell was accessible for one of 20 residents reviewed (Resident R103). Review of facility policy entitled Resident Call System dated 2/18/25, indicated Each resident is provided with a means to call staff directly for assistance from his/her bed. Review of Resident R103's clinical record revealed an admission date of 9/10/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Observations on 7/16/25, at 9:05 a.m. revealed Resident R103 in their bed with the head of the bed elevated to a sitting position and his/her call bell was lying under his/her bed. [...]
June 6, 2025Complaint inspection · 2 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R2) was free from neglect during care which resulted in actual harm of a left femur (upper leg) fracture. This deficiency is cited as past non-compliance.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility documentation and clinical record, and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care for two of three residents reviewed (Residents R2 and R3), with one transfer which resulted in actual harm of a left femur (upper leg) fracture for one of three residents reviewed (Resident R2). This deficiency is cited as past non-compliance.
November 8, 2024Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policies, facility documentation and review of clinical records, and staff interviews, it was determined that the facility failed to appropriately transfer a resident to ensure the resident was free from neglect which resulted in actual harm of a fracture of the right humeral head of the right shoulder for one of 13 residents reviewed (Resident R1).
August 9, 2024Standard inspection · 8 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R66).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form CMS-10055 as required to one of three residents reviewed (Resident R43).
- 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and/or revise resident care plans for one of 18 residents reviewed (Resident R38).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 18 residents reviewed (Residents R66, R28, and R67).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of two residents reviewed for respiratory services (Resident R293).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of six residents reviewed for unnecessary medications (Resident R10) and failed to provided evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for three of six residents reviewed for unnecessary medications (Residents R10, R38, and R293).
- 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of one medication rooms reviewed (First Floor) and the facility failed to appropriately discard outdated medications for one of two medication carts reviewed (C wing medication cart).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policy and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose (sugar) in the blood) for one of seven residents observed during the administration of medications (Resident R75).
April 18, 2024Complaint inspection · 2 citations
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the physician reviewed the residents' total program of care including medications during physician visits for one of nine residents reviewed (Resident R1).
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to properly conduct thorough monthly drug regimen reviews to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities for one of nine residents reviewed (Resident R1).
February 8, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an injury of unknown origin in a timely manner for one of one residents reviewed (Resident R1).
Fire safety inspections
12 fire safety citations on file: 6 on July 2, 2026, 5 on July 18, 2025, 1 on August 9, 2024.
Every fire safety citation12 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 2, 2026 · deficient, provider has
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 2, 2026 · deficient, provider has
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 2, 2026 · deficient, provider has
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 2, 2026 · deficient, provider has
- C
Meet other general requirements.
K 100 · July 2, 2026 · deficient, provider has
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 2, 2026 · deficient, provider has
- E
Have an enclosure around a vertical opening shaft.
K 311 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 18, 2025 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · July 18, 2025 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · July 18, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 9, 2024 · Corrected (the home has a date of correction)