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
2G
0H
0I
Potential for more than minimal harm
15D
1E
2F
Potential for minimal harm
0A
0B
0C
March 27, 2026Standard inspection · 5 citations
- 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 observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained for 2 of 2 medication rooms reviewed for medication storage. This placed residents at risk for reduced efficacy of medication.
- 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 it was determined the facility failed to ensure residents the right to a dignified dining experience for 1 of 1 sampled resident (#32) reviewed for dignity. This placed residents at risk for lack of dignity.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents and the resident's responsible party of the risks and benefits, and to ensure consent was obtained, for the use of psychotropic medications for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent of psychotropic medications.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide hygiene and grooming care to 1 of 1 sampled resident (#32) reviewed for ADLs. This placed residents at risk for unmet hygiene and grooming needs.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received seizure medications for 1 of 1 sampled resident (#25) reviewed for medications. This placed residents at risk for seizures.
March 4, 2025Complaint inspection · 1 citation
- G
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, it was determined the facility failed to ensure an environment free from accident hazards for 1 of 3 (#10) sampled residents reviewed for accidents. The facility failed to properly attach the sling with the lower leg straps to the Hoyer (a mechanical lift device used to transfer residents) during a transfer. As a result, Resident 10 sustained a left leg femoral (largest leg bone) fracture and an avulsion injury to the left foot (occurs when an injury causes a ligament or tendon to break off a small piece of a bone that is attached to it).
November 21, 2024Standard inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to serve food in a sanitary manner for 2 of 2 dining rooms. This placed residents at risk for foodborne illness.
- 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 it was determined the facility failed to ensure residents were treated with dignity for 1 of 10 sampled residents (#29) reviewed for dining. This placed residents at risk for lack of dignity.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to timely inform the resident representative of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for the lack of informed consent.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a comprehensive assessment within the required timeframe for 1 of 2 sampled residents (#2) reviewed for resident assessment. This placed residents at risk for unassessed needs.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure accurate assessments for 1 of 1 sampled resident (#31) reviewed for limited range of motion. This placed residents at risk for unassessed needs.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident with limited ROM received appropriate treatment and services to prevent further decline for 1 of 1 sampled resident (#31) reviewed for ROM. This placed residents at risk for worsening contractures.
July 24, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to timely evaluate and analyze repeated falls to ensure fall interventions were effective for 1 of 3 sampled residents (#4) and failed to ensure fall interventions were followed for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 fell and sustained a fracture.
September 8, 2023Standard inspection · 7 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview it was determined the facility failed to implement a water management program for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to water-borne illnesses.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were able to participate in care conferences for 1 of 1 sampled resident (#7) reviewed for care planning. This placed residents at risk for lack of participation in the care planning process.
- D
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 interview and record review it was determined the facility failed to periodically follow-up on advanced directives for 1 of 2 sampled residents (#10) reviewed for advanced directives. This placed residents at risk for healthcare decisions not being honored.
- D
Ensure a qualified health professional conducts resident assessments.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete and submit a discharge tracker for 1 of 1 sampled resident (#19) reviewed for assessments. This placed residents at risk for incomplete records.
- 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 observation, interview and record review it was determined the facility failed to develop and implement a comprehensive care plan for 1 of 1 sampled resident (#17) reviewed for skin conditions. This placed resident at risk for unmet skin care needs.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to honor activity preferences for 2 of 2 sampled residents (#s 10 and 30) reviewed for activities. This placed residents at risk for decline in psychosocial well-being.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacy identified drug interactions were reviewed by a resident's physician for 1 of 5 sampled residents (#33) reviewed for medications. This placed residents at risk for adverse medication reactions.
Fire safety inspections
12 fire safety citations on file: 3 on March 27, 2026, 2 on November 21, 2024, 7 on September 8, 2023.
Every fire safety citation12 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 21, 2024 · 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 · November 21, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · September 8, 2023 · Corrected (the home has a date of correction)
- F
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 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 8, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · September 8, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 8, 2023 · Corrected (the home has a date of correction)