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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
3E
0F
Potential for minimal harm
0A
0B
0C
July 24, 2026Complaint inspection · 2 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 ensure a resident's oxycodone (narcotic pain medication) was accounted for after the medication had been delivered for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on June 12, 2026, prior to the start of the survey, and was therefore past noncompliance.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for nephrostomy tube (a tube inserted through the skin of the lower back and advanced into the kidney to drain urine) site care was clarified for 1 of 3 residents reviewed for tube site care. (Resident C)
July 1, 2025Standard inspection · 5 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 observation, interview, and record review, the facility failed to ensure food was not stored beneath a water line on which water had condensed for 2 of 2 observations of the kitchen freezer.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's representative and physician were notified of significant weight loss for 2 of 7 residents reviewed for nutrition. (Resident 5, Resident 85)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 of 32 residents reviewed for accuracy of the MDS assessments. (Resident 12, Resident 152)
- 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 observation, interview, and record review, the facility failed to ensure the care plan was revised for 1 of 4 residents reviewed for accidents. (Resident 92)
- 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 staff provided the services for a resident to maintain good personal hygiene (Resident 109) for 1 of 1 resident reviewed for Activities of Daily Living (ADLs).
May 8, 2025Complaint inspection · 1 citation
- J
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 provide supervision to prevent a resident that resided on a secured memory care unit and was to be receiving one to one staff supervision for exit seeking behavior, from exiting the secured memory care unit through a window in another resident's room. The resident was found by staff approximately 2 miles from the facility. (Resident B) The Immediate Jeopardy began on April 27, 2025, when Resident B exited the secured memory care unit through another residents window. The Administrator, Regional Nurse, and Assistant Director of Nursing were notified of the Immediate Jeopardy on May 6, 2025 at 2:00 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on 4/28/25, prior to the start of the survey and was therefore Past Noncompliance.
February 7, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's rights to be free from physical abuse by a staff member for 1 of 3 residents reviewed for abuse. A staff member held down the residents arms to provide care. (Resident B, CNA 1)
August 12, 2024Standard inspection · 4 citations
- E
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 record review and interview, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and/or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160)
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 4 of 4 residents reviewed for hospitalization and discharge. (Resident 96, Resident 148, Resident 145, and Resident 160)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident could self-administer medication for 1 of 1 randomly observed resident (Resident 38).
- D
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, interview, and record review, the facility failed to ensure residents were provided an adequately lit, homelike environment for 1 of 7 units reviewed for environmental concerns. (Unit G) On the following dates and times the main hallway of the secured Unit G was observed to have dim, flickering overhead fluorescent lights, and dark colored walls void of homelike decor or adornment: - On 8/6/24 at 12:35 p.m. - On 8/6/24 at 2:40 p.m. - On 8/7/24 at 10:40 a.m. - On 8/7/24 at 12:50 p.m. - On 8/7/24 at 3:05 p.m. - On 8/8/24 at 9:28 a.m. - On 8/8/24 at 2:26 p.m. - On 8/9/24 at 12:27 p.m. - On 8/9/24 at 3:10 p.m. - On 8/12/24 at 9:45 a.m. - On 8/12/24 at 12:05 p.m. Confidential interviews were conducted during the course of the survey from 8/6/24 through 8/12/24. [...]
March 27, 2024Complaint 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 accurate reconciliation and accounting for narcotics (controlled medications) were performed for 2 of 3 shifts reviewed. (LPN 2, LPN 3, RN 4)
June 30, 2023Standard inspection · 3 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at bedside without a self medication administration assessment for 1 of 1 random observations.(Resident 79)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected resident status for 3 of 3 residents reviewed for accuracy of assessments. Level 2 PASRR (Preadmission Screening and Resident Review) and discharge status were coded incorrectly. (Resident 25, Resident 38, Resident 166)
- 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 interview and record review, the facility failed to ensure a care plan was in place for a resident who was diagnosed with a urinary tract infection for 2 of 2 residents reviewed for urinary tract infections. (Resident 34, Resident 151)
Fire safety inspections
12 fire safety citations on file: 5 on July 1, 2025, 2 on August 12, 2024, 5 on June 30, 2023.
Every fire safety citation12 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 1, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 1, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 1, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 1, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · July 1, 2025 · Corrected (the home has a date of correction)
- E
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
K 227 · August 12, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 12, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 30, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 30, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 30, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 30, 2023 · Corrected (the home has a date of correction)