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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
0E
0F
Potential for minimal harm
0A
0B
0C
April 22, 2026Standard inspection · 1 citation · risk-based survey (a shorter visit CMS gives only to higher performing homes)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and document review, the facility failed to implement appropriate monitoring for a resident taking an anticoagulant medication for 1 of 1 resident (R4) reviewed for anticoagulant medication.
December 3, 2025Complaint inspection · 4 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and document review the facility failed to honor residents right to refuse medications for 1 of 3 residents reviewed (R1) when she was administered morphine after telling staff she did not want the medication. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1's Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment. R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. The care plan identified behaviors that included calling out and refusal of medications. [...]
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on interview and document review the facility failed to ensure residents reserved the right to remain free from restraints for 1 of 3 resident (R1) when staff held her hands and administered morphine against her wishes. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1s Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment. R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. The care plan identified behaviors that included calling out and refusal of medications. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review the facility failed to report an allegation of abuse to the state agency (SA) for 1 of 3 residents (R1) reviewed who was physically restrained by staff and administered medication against her wishes. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1's Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment. R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) who was physically restrained and administered morphine against her wishes. In addition, the facility failed to implement measures to protect other residents from the alleged abuse. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included Malignant neoplasm of breast, hypertension, dementia, depression and anxiety. R1s Brief Interview for Mental Status dated 10/8/25, identified a score of seven which indicated severe cognitive impairment. R1's care plan dated 7/2525, identified impaired cognition and indicated she was at high risk for being exploited by others and would not be able to accurately report if abused. The care plan indicated staff would intervene on R1's behalf if abuse was suspected, witnessed or reported. [...]
February 6, 2025Standard inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and document review, the facility failed to assess smoking safety for 1 of 1 resident (R38) reviewed for smoking.
January 10, 2024Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of physical abuse were reported immediately (within two hours) to the State Agency (SA) for 3 of 5 residents (R2, R5, R1) reviewed for abuse.
November 9, 2023Standard inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents who were at risk for pressure ulcers were repositioned timely as directed by the residents care plan for 1 of 2 residents (R41), and failed to initiate facility wound documentation protocols, to re-evaluate turning and repositioning intervals, to revise care plan interventions, and to notify the dietician of a new wound for 1 of 2 (R115) residents reviewed for pressure ulcers.
- 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 document review, the facility failed to monitor manufacturer expiration dates on medications for 1 of 5 residents (R38) reviewed for medication storage.
Fire safety inspections
19 fire safety citations on file: 6 on April 22, 2026, 9 on February 6, 2025, 4 on November 9, 2023.
Every fire safety citation19 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have horizontal exits used in accordance with safety requirements.
K 226 · February 6, 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 6, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 6, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 6, 2025 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · February 6, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 6, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 6, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 9, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 9, 2023 · Corrected (the home has a date of correction)