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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
4E
1F
Potential for minimal harm
0A
0B
0C
February 20, 2026Standard inspection · 6 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to follow the physicians' orders related to hold parameters for cardiac medications for 2 of 16 residents reviewed for quality of care. (Residents 37 and 63)
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate transfer or discharge documentation was provided for 2 of 3 residents reviewed for transfer or discharge. (Residents 66 and 68)
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to provide a bed hold for a resident sent to the hospital for 1 of 3 residents reviewed for discharge. (Resident 66)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to follow the physicians' orders related to daily weights for 1 of 1 residents reviewed for Hydration Status. (Resident 52)
- 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 store medications appropriately for 1 of 4 medication carts reviewed and 1 of 3 medication rooms reviewed. (South Medication Cart on the third floor and third floor Medication Room)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 1 of 16 residents reviewed for infection control. (Resident 63)
September 22, 2025Complaint 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 record review and interview the facility failed to provide appropriate assistance to prevent an avoidable accident for 1 of 3 residents reviewed for accidents hazards. This deficient practice resulted in the resident acquiring right medial and right posterior orbital fractures. (Resident D)
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate equipment to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the residents bedside for 1 of 3 residents reviewed. (Resident C)
June 19, 2025Complaint inspection · 1 citation
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview, the facility failed to maintain a functional, sanitary and comfortable homelike environment related to dripping and pooling water. This deficent practice had the potiential to affect 49 of 49 residents residing in the facility.
March 17, 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 observation, interview, and record review, the facility failed to store medications appropriately related to labeling medications, cleanliness of medication carts, loose pills, discontinued medications, and expired medications for 2 of 3 Medication Carts reviewed (South Medication Cart on the third floor, North Medication Cart on the second floor) and 1 of 2 Medication Storage areas reviewed (First floor).
- 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 follow the manufacturer's guidelines related to insulin pen usage for 1 of 5 residents observed for medication administration. (Resident 12)
- 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 an accident hazard was thoroughly investigated after a resident acquired a fracture and laceration to her thumb for 1 of 3 residents reviewed for accident hazards. (Resident 13)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician ordered nutritional supplements for 1 of 2 residents reviewed for nutrition. (Resident 29)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to follow appropriate infection control guidelines during medication administration related to hand hygiene for 2 of 5 residents observed. (Residents 28 and 18)
October 2, 2024Complaint inspection · 1 citation
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to store food appropriately for 1 of 2 kitchen observations.
August 13, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate a resident's allegation of abuse for 1 of 1 abuse allegations reviewed. (Resident B)
February 9, 2024Standard inspection · 7 citations
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and record review, the facility failed to ensure a complete and accurate facility assessment based on the resident population and identification of resources needed to provide the necessary care and services required for their residents for 1 of 1 assessment reviewed.
- 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, interview, and record review, the facility failed to provide a homelike setting for 7 of 14 residents using the shower rooms on the 100 Hall related to loose wires hanging from the walls.
- 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, record review, and interview, the facility failed to ensure care plans were in place for residents related to a risk for skin impairments, resident's oral health status; and a care plan/physician's order related to the adequate assessment, and ongoing monitoring for the use of a seat belt and body positioning device for 3 of 14 residents reviewed for care plans. (Residents 14, 25, and 2)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. Medication administration was observed on 02/08/24 at 8:42 A.M., with RN 5 as she prepared insulin pens for Resident 24. The RN gathered a Lispro insulin pen and a Lantus insulin pen from a plastic bag and indicated the resident was to receive 17 units of Lispro (a short-acting insulin) with meals and 40 units of Lantus (a long acting insulin). The resident's blood glucose level had been 178. The nurse applied needles to both pens, not wiping off the rubber seal with an alcohol wipe, turned the dial at the end of the pens to the appropriate dose, used hand sanitizer, entered the resident's room, cleaned the resident's abdomen with an alcohol wipe, donned gloves, verified the resident's name, administered the two insulins, holding the pens in place for a few seconds following administration, and exited the room. [...]
- 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 adequately monitor a dialysis access site for 1 of 2 residents that received dialysis treatments. (Resident 25)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to transcribe orders on admission for 1 of 5 residents reviewed for pharmacy services. (Resident 16)
- 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 and interview, the facility failed to store medications appropriately for 2 of 3 medications rooms (Units 2 and 3) and 2 of 3 medication carts reviewed. (Units 2 and 1)
Fire safety inspections
43 fire safety citations on file: 7 on February 20, 2026, 10 on March 17, 2025, 26 on February 9, 2024.
Every fire safety citation43 citations
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · February 20, 2026 · no revisit needed
- 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 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 20, 2026 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 17, 2025 · Waiver
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 17, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 17, 2025 · Waiver
- E
Provide properly protected cooking facilities.
K 324 · March 17, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 17, 2025 · Waiver
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 17, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 17, 2025 · Corrected (the home has a date of correction)
- C
Provide a written emergency evacuation plan.
K 711 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 9, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 9, 2024 · Waiver
- E
Meet other general requirements.
K 100 · February 9, 2024 · Corrected (the home has a date of correction)
- 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 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · February 9, 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 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · February 9, 2024 · Waiver
- E
Install corridor and hallway doors that block smoke.
K 363 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · February 9, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 9, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · February 9, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 9, 2024 · Corrected (the home has a date of correction)
- B
Have properly installed electrical wiring and gas equipment.
K 511 · February 9, 2024 · Corrected (the home has a date of correction)