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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
2E
2F
Potential for minimal harm
0A
1B
1C
November 14, 2025Standard inspection, Complaint inspection · 5 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of 36 sampled residents. (Residents 12 and 26)
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 34)
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 36 sampled residents. (Resident 9)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) during medication administration on two of three nursing units. (1st and 2nd floor)
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, it was determined that the facility failed to dispose of trash and refuse properly.
August 1, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment for one of five sampled residents. (Resident 3)
February 11, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review and staff and resident interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for two of three sampled residents. (Residents 2 and 3)
November 15, 2024Standard inspection · 5 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for five of 36 sampled residents. (Residents 24, 34, 65, 95, and 145)
- 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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 36 sampled residents. (Residents 61 and 65)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on facility policy review, clinical record review, observation, and resident, staff, and family interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for four of five sampled residents who required assistance with activities of daily living (ADLs). (Residents 5, 27, 28, and 81)
- D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on review of the facility meal schedule, observation, and resident interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on one of three nursing units. (Third floor)
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of five sampled residents who were transferred to the hospital. (Residents 123, 139, and 142)
October 1, 2024Complaint inspection · 1 citation
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on resident interviews, review of facility documentation, observation, and results of a test tray evaluation, it was determined that the facility failed to provide food that was palatable and at acceptable temperatures on one of three nursing unit. (Third floor)
April 10, 2024Complaint inspection · 1 citation
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on a review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen.
December 12, 2023Standard inspection · 10 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 review of facility policy and observation, it was determined that the facility failed to store, prepare and serve foods in a sanitary manner in the food service department to prevent the potential 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 and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity for one of 39 sampled residents. (Resident 166)
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on two of three nursing units. (2nd floor, 3rd floor)
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for five of 39 sampled residents. (Residents 2, 10, 149, 266, 267)
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on clinical record review, observation, and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for two of six sampled residents who needed assistance with activities of daily living. (Residents 98, 159)
- 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 staff implemented physician's orders for one of 39 sampled residents. (Resident 266) In addition, the facility failed to ensure that a recommendation from a psychiatric consult was implemented in a timely manner for one of four sampled residents who had a diagnosis of depression. (Resident 130)
- 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 clinical record review, observation and staff interview, it was determined that the facility failed to provide appropriate treatment and services to prevent contractures and a decrease in range of motion for one of nine sampled residents with limited range of motion. (Resident 130)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions to alleviate pain were attempted prior to the administration of pain medication prescribed on an as needed basis for one of three sampled residents with physician ordered pain medications. (Resident 159)
- 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 clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were acted upon in a timely manner for one of 39 sampled residents. (Resident 17)
- 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide a therapeutic diet as ordered by the physician for one of six sampled residents who were on a therapeutic diet. (Resident 98)
Fire safety inspections
31 fire safety citations on file: 10 on November 14, 2025, 15 on November 15, 2024, 6 on December 12, 2023.
Every fire safety citation31 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 14, 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 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 14, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 14, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · November 14, 2025 · Corrected (the home has a date of correction)
- E
Address patient/client population and determine types of services needed.
E 7 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for medical documentation.
E 23 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for volunteers.
E 24 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Provide emergency officials' contact information.
E 31 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Establish staff and initial training requirements.
E 37 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 12, 2023 · Corrected (the home has a date of correction)