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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
0E
0F
Potential for minimal harm
0A
0B
0C
June 10, 2026Complaint 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 observation, interview, record review, and document review, the facility failed to ensure a vulnerable resident was protected following physical abuse allegation for 1 of 4 sampled residents (R1). The deficient practice had the potential to result in increased fear, anxiety, emotional distress, and an increased risk of psychosocial harm.
April 6, 2026Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident was free from physical abuse for 1 of 3 sampled residents (Resident 3). The deficient practice placed residents at risk for emotional distress.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure allegations of physical abuse were submitted to the state agency within 24 hours of the facility being informed of the allegation for 2 of 2 reports reviewed. The deficient practice placed residents at risk for abuse.
July 18, 2025Standard inspection · 3 citations
- D
Provide appropriate foot care.
Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence foot wound treatments were provided per the physician's order for 1 of 23 sampled residents (Resident 84). The deficient practice had the potential to place the resident at risk for delayed healing of a wound.
- 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 ensure medication was properly labeled and stored. The deficient practice had the potential for non-viable medication to be administered to a resident.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure preventative maintenance (PM) was performed annually for medical equipment being used for 2 of 23 sampled residents (Resident 30 and 40). The deficient practice had the potential for a resident not to receive the intended function of a medical device.
June 28, 2024Standard inspection · 6 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 24 sampled residents (Resident 52). The deficient practice had the potential for residents to not receive necessary behavioral health services.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence a discharge plan was initiated and discussed with the resident and/or resident representative for 1 of 24 sampled residents (Resident 190). The deficient practice had the potential for the resident to be unprepared for discharge.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure as needed (PRN) psychotropic medications were initially ordered for a duration not to exceed 14 days for 3 of 24 sampled residents (Resident 11, 64, and 188); and consents for the administration of psychotropic medications were obtained for 2 of 24 sampled residents (Resident 64 and 188). The deficient practices had the potential to cause an adverse medication effect and not honoring the resident's rights to be fully informed of the care and services being provided.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure dietary orders were followed for a resident on a renal diet for 1 of 24 sampled residents (Resident 47). This deficient practice placed the resident at risk for weight loss.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the medical record contained the nurse's notes and weekly summary form for 1 of 24 sampled residents (Resident 188). The deficient practice had the potential for the resident not to receive the timely interventions needed and for the facility missing the opportunity to identify care issues.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview, record review and document review, the facility failed to develop and implement at least one Performance Improvement Project (PIP) per year. The deficient practices had the potential to adversely impact each resident's well-being.
August 10, 2023Standard inspection · 8 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a medication self-administration assessment was completed for 1 of 28 sampled resident (Resident #35). The failed practice could potentially lead to serious medication errors, adverse drug reactions, or other health complications for the resident.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and document review, the facility failed to protect a resident's right to be free from verbal abuse by staff for one of 28 sampled residents (Resident #282). The deficient practice caused mental distress for the affected resident.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interviews, employee file review, and document review, the facility failed to implement their written procedures for screening potential employees for a history of abuse, neglect, and exploitation for two of 12 employee files reviewed (Employees 11 and 12). The deficient practice had the potential to expose residents to interactions with harmful persons.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure residents' showers or bed baths were provided as scheduled to dependent residents for 3 of 28 sampled residents (Residents 380, 46, and 48). This deficient practice could lead to compromised hygiene and discomfort, potential skin issues, and a decline in their overall well-being and quality of life.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure an assessment for the use of a sling for transfer at the dialysis center was conducted, and a physician was notified for a missed dialysis treatment for 1 of 28 sampled residents (Resident 81). This deficiency led to a situation where dialysis treatment was not provided, posing a risk to the resident's safety, potential hazards, comfort, and overall well-being.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was not five percent (%) or greater when three errors were identified with 25 opportunities observed, resulting in an error rate of 12%. Failure to reduce the medication error rate to less than 5% could lead to an adverse drug reaction from an overdose or underdose, which can cause harm or injury to the resident.
- 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 ensure bedside medication for resident's self-administration was secured for 1 of 28 sampled resident (Resident #35). The failed practice could potentially lead to misappropriation of a resident's medication by another resident or staff.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the resident's dietary restriction or food preference was followed or implemented for 1 of 28 sampled residents (Resident 81). This deficient practice had the potential to trigger allergic reactions, endangering residents' health and leading to severe medical complications or adverse reactions.
Fire safety inspections
41 fire safety citations on file: 14 on July 18, 2025, 9 on June 28, 2024, 18 on August 10, 2023.
Every fire safety citation41 citations
- F
Have properly installed electrical wiring and gas equipment.
K 511 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · July 18, 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 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 18, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 18, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · July 18, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · July 18, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 28, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 28, 2024 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · June 28, 2024 · Corrected (the home has a date of correction)
- E
Create arrangements with other facilities to receive patients.
E 25 · June 28, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 28, 2024 · Corrected (the home has a date of correction)
- D
Include a process for Emergency Preparedness collaboration.
E 9 · June 28, 2024 · Corrected (the home has a date of correction)
- D
Develop a communication plan.
E 29 · June 28, 2024 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · June 28, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 28, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · August 10, 2023 · 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 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure gas cylinders are properly stored.
K 906 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 10, 2023 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · August 10, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 10, 2023 · Corrected (the home has a date of correction)