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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
5E
1F
Potential for minimal harm
0A
0B
1C
November 17, 2025Standard inspection, Complaint inspection · 3 citations
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure systems were in place to prevent multiple incidents of misappropriation of a residents' medication for 9 (#s 14, 15, 16, 18, 20, 23, 38, 48, and 52) of 25 sampled residents.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff members M and N reported a reasonable suspicion of a crime, related to diversion of medication, in a timely manner to administrative personnel.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a weight gain greater than 3 pounds in 2 days or 5 pounds in a week for 1 (#22) of 25 sampled residents.
September 12, 2024Standard inspection · 7 citations
- G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide psychiatric services for 1 (#40) of 1 resident with the diagnoses: Borderline Personality Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Epilepsy, Other Drug Induced Secondary Parkinsonism, as shown in resident #40's EHR.
- E
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to answer call lights timely, for 6 (#s 9, 17, 24, 36, 39, and 202) of 13 sampled residents.
- 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 observation, interview, and record review the facility failed to have the advance directive for 1 (#17) of 1 resident located in the Disaster Recovery Binder, easily accessible to staff during an emergency.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's care plan accurately showed the resident's current non-use of interventions for a wheelchair cushion, and for bedside rails, for 1 (#37) of 13 sampled residents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient interventions for 1 (#40) of 2 residents who had severe weight loss. Resident #40 was self-limiting her intake which contributed to the weight loss. This resident had the diagnoses: Borderline Personality Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Epilepsy, Other Drug Induced Secondary Parkinsonism, as shown in resident #40's EHR and was not consulted with psychiatry.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow physician orders to change oxygen tubing for 1 (#34) of 3 sampled residents. This increased the potential for respiratory infection and medical decline.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a legible daily nurse staffing posting was placed with the required information, including the census, and that is was posted in an area easily accessible to residents or anyone wishing to view the information. This deficient practice would affect anyone wanting to view the information.
May 20, 2024Complaint inspection · 2 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, the facility failed to have and maintain a sanitary kitchen, staff failed to follow hygienic practices, and failed to take and record temperatures for food storage and for food during meal service. These deficient practices had the potential to affect all residents consuming food from the facility kitchen.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the State Survey Agency for 1 (#9) in the required timeframe; and failed to report incident findings to the State Survey Agency within the five-day required time frame, for 5 (#s 1, 5, 8, 10, and 11) of 11 sampled residents.
November 6, 2023Complaint inspection · 1 citation
- E
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 create baseline care plans with the necessary information to safely address the resident's needs, within the 48-hour timeline, for 4 (#s 2, 3, 6, and 8) of 8 sampled residents.
August 30, 2023Standard inspection · 2 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was safe to self-administer medications, before leaving the medications at bedside, causing an increased risk for medications not being taken as the physician prescribed, for 1 (#15) of 5 sampled residents for self-administration of medications.
- 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 and record review, the facility failed to ensure a PRN (as needed) psychotropic medication prescription had a rationale for continuation, and stop date, for 1 (#33) of 5 sampled residents taking psychotropic medications.
Fire safety inspections
13 fire safety citations on file: 3 on November 17, 2025, 4 on September 12, 2024, 6 on August 30, 2023.
Every fire safety citation13 citations
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 17, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 17, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 30, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 30, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 30, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 30, 2023 · Corrected (the home has a date of correction)
- D
Provide properly sized and located linen or trash receptacles.
K 754 · August 30, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 30, 2023 · Corrected (the home has a date of correction)