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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
24D
0E
0F
Potential for minimal harm
0A
0B
0C
January 29, 2026Standard inspection · 0 citations
October 14, 2025Complaint inspection · 1 citation
- 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 interview and record review, the facility failed to follow its advance directive/life sustaining policy by not having power of attorney implemented for a resident. This applies to 1 of 3 (R1) residents reviewed for advance directives in a sample of 3.
August 20, 2025Complaint inspection · 1 citation
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interviews and record review, the facility failed to reconcile a residents' (R1) discharge medications with current prescription orders prior to discharging the resident. This failure affected two of three residents (R1, R3) reviewed for medications in the sample of three and resulted in several of R3's medications being found within R1's accompanying medications after discharging home.
June 24, 2025Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident received their scheduled medication for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3.
March 12, 2025Complaint inspection · 3 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review the facility failed to protect a resident from the misappropriation of resident property when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to report to the state surveying agency an allegation of misappropriation of resident property immediately, but not later than 24 hours when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to have evidence that an allegation of misappropriation of resident property was thoroughly investigated for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3.
November 20, 2024Standard inspection · 10 citations
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a newly admitted resident on tube feeding was weighed weekly. This failure resulted in R125 losing 16.8 pounds (11.4% weight loss) in 18 days. The facility failed to monitor weights, assess residents who have had a significant weight loss and implement interventions to prevent further weight loss. This failure resulted in R20 losing 12.6 pounds (7.67% weight loss) in 1 month and R231 losing 10.2 pounds (6.6% weight loss) in 13 days. This applies to 3 of 5 residents (R20, R125 and R231) reviewed for nutrition in the sample of 26.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's legs were properly supported while sitting in her wheelchair for 1 of 26 residents (R57) reviewed for accommodation of need in the sample of 26.
- 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 interview and record review the facility failed to ensure a resident's advanced directives were discussed and implemented upon admission for 1 of 26 residents (R282) reviewed for advanced directives in the sample of 26.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who require staff assistance with ADLs (Activities of Daily Living) received showers/baths. This applies to 2 of 26 (R58, R39) residents reviewed for activities of daily living in the sample of 26.
- D
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 ensure a gait belt was used during a transfer and failed to ensure interventions were added to a resident's plan of care after a fall to prevent additional falls for 2 of 26 residents (R39 and R110) reviewed for safety in the sample of 26.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was administered oxygen using a high flow nasal cannula for 1 of 6 residents (R281) reviewed for oxygen administration in the sample of 26.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff administered medications to a resident and not leave them on the bedside table. This applies to 1 of 26 residents (R15) reviewed for pharmacy services in the sample of 26.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error. This applies to 1 of 26 residents (R58) reviewed for medications administration in the sample of 26.
- 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, interview, and record review the facility failed to ensure medications were securely stored for 1 of 26 residents (R121) reviewed for medication storage in the sample of 26.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility staff failed to wash their hands and change their gloves to prevent the spread of infection and failed to ensure staff donned all applicable Personal Protective Equipment for a resident with Enhanced Barrier Precautions (EBP) for 2 of 26 residents (R20 and R12) reviewed for infection control in the sample of 26.
October 31, 2024Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility staff failed to ensure residents who required staff assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 4 residents (R2, R1) reviewed for ADLs in the sample of 9.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to assist a resident with eating and failed to ensure a nutritional intervention was implemented for a resident with significant weight loss. This failure resulted in R4 sustaining significant weight loss. These failures apply to 1 of 4 residents (R4) reviewed for weight loss in the sample of 9.
August 26, 2024Complaint inspection · 1 citation
- G
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 observation, interview and record review the facility failed to report adverse side effects immediately, failed to monitor the use of psychotropic medications, and failed to carry out the orders to hold medication for a resident showing signs of adverse effects of excessive drowsiness. This failure resulted in R1 being sent out to the hospital for evaluation for stroke like symptoms. This applies to 1 of 3 residents (R1) reviewed or unnecessary medications in the sample of 5.
July 24, 2024Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, interview and record review the facility failed to protect a resident's right to be free from misappropriation of resident property. This applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 8.
December 27, 2023Complaint inspection · 1 citation
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's peritoneal dialysis treatments were initiated and monitored which applies to 1 of 1 resident (R1) reviewed for dialysis services in a sample of 1.
December 6, 2023Standard inspection · 5 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to implement physician ordered wound interventions for 1 of 24 residents (R93) reviewed for non-pressure wounds in the sample of 24.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a soiled dressing was changed, failed to reposition a resident with pressure injuries, and failed to have pressure relieving interventions in place for 2 of 5 residents (R40, R81) reviewed for pressure injuries in the sample of 24.
- D
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 ensure fall interventions were in place for a resident with a history of falls. This applies to 1 of 24 residents (R51) reviewed for safety in the sample of 24.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess a resident's pain every shift and provide pain medication prior to therapy. This applies to 1 of 24 residents(R23) reviewed for pain in the sample of 24.
- 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, interview, and record review the facility failed to ensure a residents insulin vial was disposed of after 28 days of opening and failed to ensure a medication vial for anti-anxiety was dated and labeled upon opening. This applies to 2 of 6 residents (R80 and R37) reviewed for medication storage in the sample of 24.
Fire safety inspections
25 fire safety citations on file: 10 on January 29, 2026, 6 on November 20, 2024, 9 on December 6, 2023.
Every fire safety citation25 citations
- F
Establish roles under a Waiver declared by secretary.
E 26 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Have proper power supply for life support equipment.
K 915 · January 29, 2026 · 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 · January 29, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 29, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 29, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 29, 2026 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · November 20, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · November 20, 2024 · 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 · November 20, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the use of electrical equipment.
K 919 · November 20, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 20, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 20, 2024 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · December 6, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 6, 2023 · Corrected (the home has a date of correction)