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
0G
0H
0I
Potential for more than minimal harm
15D
0E
0F
Potential for minimal harm
0A
0B
0C
April 15, 2026Standard inspection · 7 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 that a resident that self-administered medications was assessed as clinically appropriate for 1 of 2 residents reviewed for choices in a final sample of 20 residents. (Resident identifier is #31.)
- 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 send a copy of the notice of transfer to the Long-Term Care (LTC) Ombudsman for 2 of 3 closed records reviewed and 1 of 2 hospitalizations reviewed in a final sample of 20 residents (Resident Identifiers are #77, #1, and #79).
- 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 follow professional standards for 1 out of 5 residents observed for medication administration and for 2 of 2 wound care observations in a final sample of 20 residents (Resident Identifiers are #16, #51, and #7).
- 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 administer drugs and biologicals to 1 of 1 resident reviewed for new admissions in a final sample of 20 residents (Resident Identifier is #82).
- 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 policy review, the facility failed to permit only authorized personnel to have access to medication room keys for 2 of 2 medication rooms observed.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to ensure that a staff was offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine for 1 of 1 staff reviewed for COVID-19 vaccination. (Staff identifier is H.)
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain two equipment per manufacturer's instruction for 1 of 1 resident reviewed for respiratory care and 1 of 1 portable air conditioner observed.
March 21, 2025Standard inspection · 5 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications were appropriate for 1 of 2 residents reviewed for choices in a final sample of 18 residents (Resident identifier is #25).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to refer residents with an evident or possible serious mental disorder for a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 1 resident reviewed for PASARR in a final sample of 18 residents (Resident identifier is #16).
- 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, it was determined that the facility failed to implement the plan of care for 1 of 1 resident reviewed for change of condition (Resident identifier is #32) and 1 of 1 resident reviewed for insulin (Resident identifier is #58) in a final sample of 18 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that insulin was administered per manufacturer's instructions and per facility policy and procedure for 1 of 4 residents observed for medication administration. (Resident identifier is #77.)
- 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, it was determined that the facility failed to ensure that medications were appropriately labeled and expired medications removed from use for 1 of 2 medication carts observed.
June 4, 2024Complaint inspection · 1 citation
- J
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that 1 of 4 residents reviewed for insulin was free from exposure to bloodborne and bacterial pathogen transmission when staff administered the resident insulin from another resident's used insulin pen (Resident Identifier #1).
February 29, 2024Standard inspection · 3 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wrote1) Based on observation, record review, and interview it was determined that the facility failed to follow physicians' orders to provide compression stockings for 1 of 1 resident reviewed for edema in a final sample of 27 (Resident Identifier #14).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to maintain an environment free of accident hazards for 1 of 2 residents reviewed for smoking in a final sample of 27 residents (Resident Identifier #20).
- 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, it was determined that the facility failed to serve food in accordance with professional standards in 1 of 2 dining rooms observed. Findings Include: Observation on 2/27/2024 at 12:40 pm of the third floor lunch meal service revealed that Staff F (Licensed Nursing Assistant) served a hamburger to a resident by placing the top bun onto the burger with bare hands and handing the hamburger to the resident. Interview on 2/27/2024 at 12:45 with Staff F confirmed the above findings. Review on 3/4/24 of the Food Code, U.S. Public Health Service, U.S. Food and Drug Administration, 2017 retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: Preventing Contamination by Employees 3-301.11 Preventing Contamination from Hands . [...]
Fire safety inspections
12 fire safety citations on file: 4 on April 15, 2026, 4 on March 21, 2025, 4 on February 29, 2024.
Every fire safety citation12 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 15, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · April 15, 2026 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 15, 2026 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · April 15, 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 · March 21, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 21, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 21, 2025 · Corrected (the home has a date of correction)
- C
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 21, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 29, 2024 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 29, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · February 29, 2024 · Corrected (the home has a date of correction)