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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
3E
0F
Potential for minimal harm
0A
0B
0C
May 14, 2026Standard inspection · 5 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for seven out of seven residents reviewed (Resident 2, Resident 3, Resident 6, Resident 21, Resident 101, resident 108, and Resident 106,).
- 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 review of facility policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to timely notify the resident's representative and medical provider of significant changes in physical condition resulting in hospitalization for two out of seven residents reviewed (Resident 6 and Resident 101).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for one of 22 residents reviewed. (Resident 79).
- 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 interviews, it was determined that the facility failed to appropriately assess a wound for one of four residents reviewed (Resident 1) and failed to ensure that medications ordered by physicians were available for one of 22 residents reviewed (Resident 52).
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of four residents reviewed (Resident 103) who had an indwelling urinary catheter.
April 14, 2026Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on a review of resident clinical records, select facility policies, and staff interview, it was revealed the facility failed to ensure that one of the five residents sampled was free of a significant medication error (Resident 1).
June 6, 2025Standard inspection · 4 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased upon review of facility policy and procedure and review of facility documentation, it was determined the facility failed to report an allegation of abuse for one of one resident reviewed (Resident 101).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased upon review of facility policy and procedure and review of facility documentation, it was determined the facility failed to investigate an allegation of abuse for one of one resident reviewed (Resident 101).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for three of three residents reviewed. (Resident 40, Resident 42 and Resident 50).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observations, and resident interview, it was determined the facility failed to follow a physician's order for oxygen therapy for one of four residents reviewed (Resident 50).
May 31, 2024Standard inspection · 5 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy and procedure review, clinical record review, and staff interviews, it was determined the facility failed to thoroughly investigate incidents for three of 32 residents reviewed. (Residents 2, 95, and 155)
- E
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 follow the physician's orders and notify the physician of missed medications for three of the 24 residents reviewed (Residents 9, 51, and 95).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical records review, facility documentation review, and staff interviews, it was determined that the facility failed to provide appropriate assessment and supervision to prevent a fall for one of the 24 residents reviewed (Resident 35).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on a review of the facility's policy, observation, clinical records review, and resident and staff interview, it was determined that the facility failed to ensure a physician order for Oxygen use was in place for one of the residents reviewed (Resident 205).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to ensure residents did not receive unnecessary medications for one of six residents reviewed. (Resident 79) Findings Include: Review of facility policy and procedure titled Definition of Infections for Surveillance Activities, last reviewed May 16, 2024 revealed Identification of infection should not be based on a single piece of evidence but should always consider the clinical presentation and any microbiologic (lab studies) or radiologic (X-rays, CT scan etc.) information that is available. Microbiologic and radiologic findings should not be the sole criteria for defining an event as an infection. [...]
September 15, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that physician orders were followed and insulin administration was given timely for three of four residents reviewed (Residents R2 R3, and Resident R4). Findings Include: Review of Resident R2's clinical record revealed diagnoses including but not limited to Diabetes Mellitus (impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood). Review of Resident R2's clinical record revealed a physician's order for Lantus (long acting insulin) SoloStar Solution Pen-Injector 100 UNIT/ML (mililiter) with instruction to Inject 10 unit subcutaneously (under the skin) one time a day for diabetic, give 8 am. [...]
Fire safety inspections
15 fire safety citations on file: 4 on May 14, 2026, 3 on June 6, 2025, 8 on May 31, 2024.
Every fire safety citation15 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 14, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 14, 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 · May 14, 2026 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 14, 2026 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · June 6, 2025 · 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 · June 6, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 6, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 31, 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 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 31, 2024 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · May 31, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 31, 2024 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · May 31, 2024 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 31, 2024 · Corrected (the home has a date of correction)
- C
Properly provide smoke detection systems in areas open to corridors.
K 347 · May 31, 2024 · Corrected (the home has a date of correction)