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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
5E
0F
Potential for minimal harm
0A
0B
0C
May 1, 2026Complaint inspection · 1 citation
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed the resident the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #1) of 5 residents reviewed for resident rights.-The facility failed to ensure Resident #1's call system was within reach. This failure could place residents at risk of not receiving assistance when required or needed.
August 7, 2025Standard inspection · 0 citations
April 15, 2025Complaint 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 interviews and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (CR #1) of 5 residents reviewed for accidents and supervision. The facility failed to ensure CNA A and CNA B did not improperly transfer CR #1. CNA A and CNA B transferred CR #1 without a gait belt from the bed to the shower chair on 04/01/25. This failure could place residents at risk for harm, pain, and injury.
June 6, 2024Standard inspection, Complaint inspection · 1 citation
- E
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, interview, and record review the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment, for 3 of 6 residents (Resident #19, Resident #47, and Resident #13) reviewed for residents' rights. The facility failed to keep Resident #19's and Resident #47's room free of trash. The facility failed to keep Resident #13's wall clean. These failures could place residents at risk of an unsanitary environment.
April 25, 2023Standard inspection · 5 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 2 of 6 residents (Resident #42 and Resident #159 ) reviewed for pharmacy services. - The facility failed to ensure that the 100 hall nursing cart did not contain expired insulin for Resident #42 - The facility failed to have Hydrocodone- Acetaminophen, a pain medication, available for administration to Resident #159 and failed to administer it according to physician orders. This failure could place residents at risk of not receiving the therapeutic benefit of medications. Findings Included Resident #42 Record review of Resident #42's Face Sheet dated 04/24/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: [...]
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 15 percent based on 7 errors out of 44 opportunities, which involved 4 of 7 residents (Resident #37, Resident #159, Resident #16 and Resident #6) reviewed for medication errors. - LVN A failed to administer medications as ordered to Resident #37 as ordered by attempting to administer HumaLOG Insulin (Insulin Lispro) outside of parameters instead of Basaglar Insulin as ordered. [...]
- 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 the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (100 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 100 Hall Nursing Cart did not contain insulin pens with no open dates for Resident #10, Resident #37 and Resident #77. This failure could place residents at risk of adverse medication reactions. Findings Included: Resident #10 Record review of Resident #10's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: hypoglycemia and type 2 diabetes. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance for 4 of 4 residents (#159, #15, #40, #10) on puree and regular diets. The facility failed to ensure that puree diet was prepared by methods that conserve nutritive value, flavor, and appearance. This failure could place residents on regular and pureed diet at risk of experiencing a decreased quality of life and possible weight loss.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 6 residents (Residents #37 ) reviewed for significant medication errors; - LVN A failed to administer medications as ordered to Resident #37 by attempting to administer 18 units of HumaLOG Insulin (Insulin Lispro), a fast acting insulin, instead of 18 units of long acting Basaglar Insulin. This failure could place residents at risk of adverse reactions such as hypoglycemia (low blood sugar) and hospitalization. Findings Included: Record review of Resident #37's Face Sheet dated 04/24/23 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes . [...]
Fire safety inspections
5 fire safety citations on file: 2 on August 7, 2025, 1 on June 6, 2024, 2 on April 25, 2023.
Every fire safety citation5 citations
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 25, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 25, 2023 · Corrected (the home has a date of correction)