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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
13D
1E
0F
Potential for minimal harm
0A
0B
0C
June 24, 2026Complaint 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 observation, facility policy review, clinical records review, and interviews with staff and residents, it was determined that the facility failed to follow the care plan for one of the three residents reviewed (Resident 1).
February 20, 2026Standard inspection · 3 citations
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and Staff interview, the facility failed to develop and implement a baseline care plan for each resident that includes the minimum healthcare information to properly care for a resident for one out of 15 residents reviewed (Resident 45).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure physicians' orders were followed and bowel movement was appropriately monitored and addressed for two out of 15 residents reviewed (Residents 29 and 54).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on Staff interview, observation and record review, the facility failed to administer parenteral fluids in accordance with physician orders for one out of 15 resident reviewed (Resident 26).
March 14, 2025Standard inspection, Complaint inspection · 6 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 facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined the facility failed to ensure one of eight residents reviewed was provided with adequate supervision to prevent accidents for one resident (Resident 208) which resulted in actual harm when Resident 208 fell resulting in a fracture clavicle.
- 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 reviews, staff interviews, and facility policy reviews, it was determined that the facility failed to implement the comprehensive care plan approaches to prevent accidents for one of eight residents reviewed. (Resident 208)
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 45).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding medication was followed for one of the 16 residents reviewed (Resident 12).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to follow a wound specialist's recommendation for wound treatment for one of the two residents reviewed (Resident 25).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy review, clinical records review, and staff interviews, it was determined that the facility failed to ensure appropriate monitoring of weight and food intake was done and that significant weight change was timely addressed for one of 16 residents reviewed (Resident 20).
February 1, 2024Standard inspection · 6 citations
- J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on a review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for Resident 207, creating a situation for one of six residents were placed in an Immediate Jeopardy situation related to failure to perform cardiopulmonary resuscitation.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on a review of their job descriptions it was determined that the Continuing Care Administrator (CCA), and the Director of Nursing (DON) did not effectively manage the facility to ensure that CardioPulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the three units observed (Cardinal 2).
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to complete a discharge summary for one of three residents reviewed. (Resident 50) Findings Include: Review of resident's records revealed a progress note dated [DATE], at 2:36 am, noting the resident discharged to [NAME] Hospital at approximately 1:30 am. Resident noted to have shortness of breath, pulse ox was 56% on room air. Resident was put on O2 @ 5liters via nasal cannula. Pulse ox was up 82%. Resident was lethargic, sweaty and could not respond much when name was called. Blood sugar was 256, vital signs were unstable. Nursing supervisor called on-call doctor and resident was sent out via EMS. POA was made aware before resident was sent out to hospital. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding blood sugar was followed for one of the 17 residents reviewed (Resident 19).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy services provided medications timely for one of the 17 residents reviewed. (Resident 19).
Fire safety inspections
9 fire safety citations on file: 3 on February 20, 2026, 3 on March 14, 2025, 3 on February 1, 2024.
Every fire safety citation9 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 14, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 1, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 1, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 1, 2024 · Corrected (the home has a date of correction)