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
1G
0H
0I
Potential for more than minimal harm
10D
3E
2F
Potential for minimal harm
0A
0B
0C
June 29, 2026Standard inspection · 5 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's pain was managed in accordance with the resident's care plan and preferences for 1 (#57) of 23 sampled residents. This deficient practice resulted in resident #57 having moderate to severe pain from a fracture. This deficient practice increased the likelihood of other residents with pain not being managed.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the washer area of the laundry room was clean and kept free of debris; and the facility staff failed to ensure proper glove use and hand hygiene during glucose testing process for 1 (#65) of 23 sampled residents. This failure had a likelihood of contaminating resident clothes and facility linens while being washed and transferred to the dryer and increased the risk of bloodborne pathogen contamination and/or infection for residents receiving care on the 100-hall unit.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the interdisciplinary team assessed and determined residents were safe to self-administer medications prior to residents self-administering medications for 2 (#s 30 and 66) of 5 residents observed for medication administration. This deficient practice increased the likelihood of medication errors for all residents receiving medication in the facility, including failure to take clinically significant medications.
- D
Honor the resident's right to choose his or her attending physician.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor the residents' rights to choose their attending physician for 1 (#57) of 23 sampled residents. This deficient practice affected all residents wanting to choose their primary physician and resulted in resident #57 feeling she could not use her primary physician she had built a relationship with and was comfortable using.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review, the facility failed to honor a resident's preference for three showers a week for 1 (#6) of 23 sampled residents. This deficient practice resulted in the resident frequently receiving only one shower a week.
June 2, 2026Complaint 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 observation, interview, and record review, the facility failed to prevent a resident elopement for 1 (#3) of 13 sampled residents. This failure resulted in resident #3 exiting the alarmed facility and walking four blocks, and facility staff returning him to the facility uninjured. The facility had corrected the deficient practice resulting in past non-compliance.
June 30, 2025Standard inspection, Complaint inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wrote4. During an observation and interview on 6/28/25 at 2:50 p.m., the Team 2 medication room was found to have a variety of supplies and medications stacked in the corner and on the floor of the room which was an infection control concern. Staff member C said the room was too small for the amount of medication and supplies stored in the room. Staff member C said she asked administration for shelving to be able to provide more room for medication storage, but it had not been provided, so the items remained on the floor. During an observation and interview on 6/29/25 at 9:52 a.m., the Team 1 medication room had a variety of supplies covering the countertop. A used, personal cup, was in the sink. The counter was soiled and without a cleanable surface, and an infection control concern, due to the number of items stacked on the countertop. [...]
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure advance directives were complete and matched the current EHR code status for 3 (#s 1, 29, and 65) of 20 sampled residents.
- E
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 interview and record review, the facility failed to record the temperatures for the medication storage refrigerator, in the team one medication storage room. The deficient practice increased the risk of medications being stored at incorrect temperatures, if the temperatures were not monitored by staff.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided during peri care for 1 (#1) of 20 sampled residents. The resident specifically stated she did not want to be exposed.
March 27, 2025Complaint inspection · 4 citations
- E
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 prevent the elopement of 3 (#s 4, 6, and 7) of 6 sampled residents for elopement; and failed to implement an effective elopement prevention and monitoring system for 6 (#s 4, 6, 7, 8, 9, and 10) of 6 sampled residents for elopement risk. This deficient practice increased the risk of an elopement or negative outcome for a resident who was at risk of eloping, due to the system failure.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to follow admission physician orders related to TED hose/antiembolism stockings for a post op patient for 1 (#2) of 3 rehab patients sampled.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review, the facility failed to ensure it provided behavioral health services to meet the needs of 1 (#4) of 6 sampled residents for behaviors.
- 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 have a process in place to ensure pill contents, contained in personal prescription medication bottles brought from resident homes, were verified before dispensing, for 1 (#2) of 3 rehab residents sampled.
August 15, 2024Standard inspection · 2 citations
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review, the facility failed to include a resident's history and risk of suicide on the baseline care plan for 1 (#76) of 2 sampled residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate care and communication with hospice, for 2 (#s 65 and 76) of 2 sampled residents for hospice.
Fire safety inspections
12 fire safety citations on file: 4 on June 29, 2026, 5 on June 30, 2025, 3 on August 15, 2024.
Every fire safety citation12 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · June 29, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 29, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 29, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 29, 2026 · 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 · June 30, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 30, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 30, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 30, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · June 30, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 15, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 15, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 15, 2024 · Corrected (the home has a date of correction)