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
15D
2E
0F
Potential for minimal harm
0A
4B
1C
June 8, 2026Complaint inspection · 2 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical record, facility documentation, facility policy and interviews, for 3 residents (Resident #9, 1 and 50), the facility failed to administer medications and/or monitor blood sugar according to professional standards and physician's orders. For 1 resident (Resident #9) reviewed for medication errors, the facility failed to ensure staff followed the physician's order for Xanax (antianxiety medication) administration after a change in the dose. For 1 of 5 residents (Resident #1) who were reviewed for unnecessary medications, the facility failed to ensure blood glucose monitoring was performed as prescribed by the provider. [...]
- D
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 clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #19/victim and Resident #71/victim) reviewed for abuse, the facility failed to protect Resident #19 from physical abuse by Resident #9/perpetrator, who had a history of pinching and for Resident #71 the facility failed to protect Resident #71 from physical abuse by Resident #68/perpetrator.
May 19, 2026Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure adequate supervision and assistance during transfers. Specifically, staff failed to recognize and respond to signs of increasing transfer instability in the weeks prior to a fall; failed to recognize that Resident #1 was unable to bear weight at the initiation of a transfer and continued the transfer without seeking assistance; left Resident #1 unattended on the floor following a fall with a head strike; and transferred Resident #1 off the floor despite observable signs of significant pain. Resident #1 subsequently sustained an acute intertrochanteric fracture of the right proximal femur requiring surgical repair. [...]
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pain management, the facility failed to manage Resident #1's pain in accordance with facility policy and the resident's care plan. Specifically, licensed nurses failed to reassess pain within one (1) hour after administration of as-needed pain medication on multiple occasions; failed to recognize observable signs of significant pain during post-fall transfers as a change in condition requiring provider notification; and failed to administer pain medication in a timely manner following a fall that resulted in a major injury. Resident #1 subsequently sustained an acute intertrochanteric fracture of the right proximal femur requiring surgical repair. [...]
October 23, 2025Complaint 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 clinical record, facility documentation, and facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure resident was transferred safely to prevent an injury.
November 26, 2024Complaint inspection · 2 citations
- 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, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure resident was free from mistreatment.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely.
November 8, 2024Standard 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 observations, staff interviews, and review of facility policy, the facility failed to ensure foods were dated when opened and staff personal food/fluids were not stored in the facility walk-in refrigerator.
- 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 interviews and record reviews for 2 of 2 residents, (Resident #40 and Resident #46) reviewed for advance directives, for Resident #40, the facility failed to transcribe advance directives according to the signed resident's wishes and for Resident #46, the facility failed to ensure the advance directive consent had been signed and available in the medical record.
- 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 staff interview, observations, review of the clinical record, and facility policy for 1 of 8 residents (Resident #13) reviewed for accidents, the facility failed to implement fall prevention interventions as per the Resident Care Plan (RCP).
- 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 only sampled resident (Resident #30), reviewed for a change in condition, the facility failed to follow the physician order for blood sugars and blood pressures, and for 1 of 2 residents (Resident #34), reviewed for accidents and hazards, the facility failed to administer medications to the appropriate resident.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #34) reviewed for nutrition, the facility failed to appropriately supervise a resident during mealtime per the physician's order and during the initial facility tour, the facility failed to ensure water temperatures were maintained within acceptable parameters of 105 to 120 degrees Fahrenheit for 17 of 50 rooms.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of the clinical record, facility policy and interviews for the only sampled resident, (Resident #49), reviewed for hemolytic treatment, the facility failed to communicate a new allergy to the treatment center.
- B
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, interviews, and review of facility policy for 1 of 3 units for 1 resident (Resident #6), the facility failed to ensure furniture was in good repair to provide a home-like environment.
- B
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 review of clinical records, facility documentation, facility policy and interviews for 6 residents, (Resident #3, Resident #51, Resident #588, Resident #52 and Resident #12) reviewed for grievances, the facility failed to investigate grievances.
June 26, 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for elopement risk, (Resident #1), the facility failed to ensure a resident who was at risk for elopement did not leave the building unsupervised.
June 30, 2022Standard inspection · 3 citations
- 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, review of facility's documentation, review of the facility's policy and interviews for 2 of 2 sampled residents (Resident #26 and #49) reviewed for resident-to-resident abuse, the facility failed to ensure the residents were free from physical abuse.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 2 sampled residents (Resident #229) reviewed for respiratory care, the facility failed to provide necessary respiratory care consistent with professional practices.
- B
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 observation, review of clinical records, review of facility documentation, review of facility policy and interviews for 4 of 4 sampled residents (Residents #1, #33, #34 and #51) who were at risk for elopement, the facility failed to ensure the resident's wanderguard bracelets were tested daily for functioning per policy.
November 8, 2019Standard inspection · 6 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident reviewed for abuse (Resident #6), the facility failed to report an allegation of sexual mistreatment to the State Agency.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident reviewed for abuse (Resident #6), the facility failed to thoroughly investigate an allegation of mistreatment.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, review of clinical record, review of facility policy, and staff interviews for one resident observed with unattended medication (Resident #5), the facility failed to ensure medication was administered according to professional standards of practice.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, clinical record review, review of facility policy, and interviews for 1 of 4 sampled residents reviewed for nutrition, (Resident #20), the facility failed to ensure a monthly weight was completed for a resident with a weight loss.
- C
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 review of clinical record, facility documentation, facility policy and interviews for one of one sampled resident reviewed for hospitalization (Resident #5), the facility failed to notify the long-term care Ombudsman of an acute care hospital transfer with admission.
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on clinical record reviews, review of facility documentation, and interview for 12 of 19 residents reviewed for Quarterly Minimum Data Set (MDS) assessments (Resident #2, Resident #3, Resident #7, Resident #8, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, and Resident #21), the facility failed to ensure timely completions of Quarterly MDS assessments.
Fire safety inspections
6 fire safety citations on file: 3 on November 8, 2024, 2 on June 30, 2022, 1 on November 8, 2019.
Every fire safety citation6 citations
- 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 · November 8, 2024 · 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 · November 8, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 8, 2024 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · June 30, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 30, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 8, 2019 · Corrected (the home has a date of correction)