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 11 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
2E
1F
Potential for minimal harm
0A
0B
0C
March 10, 2026Standard inspection · 4 citations
- E
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 review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Residents #3, 33 and 12) reviewed for unnecessary medications, for Resident #3 and 33, the facility failed to ensure monthly pharmacy medication regimen reviews were completed for 5 of the 12 months reviewed and for 1 of 5 residents Resident #12 the facility failed to ensure monthly pharmacy medication reviews were completed 11 of 12 months.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, review of facility documentation, facility policies, and interviews, the facility failed to ensure food service staff were wearing hair restraints while preparing food and failed to ensure a low temperature dishwasher was operating in accordance with the manufacturer's recommendation.
- 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, review of facility documentation and interviews the facility failed to ensure a clean and homelike environment.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #12) reviewed for accidents, the facility failed to ensure a resident with a customized wheelchair was re-assessed for safe transfers after implementing a new standing mechanical lift and sling harness resulting in staff having to lower the resident on a firm surface near the floor.
June 17, 2024Standard inspection, Complaint inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, review of facility documentation, and interviews for 1 of 3 sampled residents (Resident #18) who were reviewed for falls, the facility failed to utilize a gait belt during a transfer resulting in a major injury from a fall.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on the tour of the Dietary Department, staff interview, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure canned foods in the emergency stock were not expired, and failed to ensure food was served under sanitary conditions.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #5) reviewed for oxygen use, the facility failed to ensure oxygen tubing was connected to the concentrator providing oxygen on 2 occasions.
- 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 clinical record review, interviews, and facility policy for 1 of 5 sampled residents (Resident #14) reviewed for unnecessary medications, the facility failed to attempt a Gradual Dose Reduction (GDR) for a psychotropic medication.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interviews for 1 of 5 sampled residents (Resident #1) reviewed for the environment, the facility failed to maintain adequate temperatures for a resident refrigerator on the 2nd floor.
April 14, 2022Standard inspection · 2 citations
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observations, clinical record review, facility documentation review, and interviews for one of two dining rooms observed, the facility failed to ensure that adaptive dining equipment was in place for one observed resident (Resident #12) during a meal in accordance with the resident plan of care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure the laundry room and linens were maintained in a clean manner.
Fire safety inspections
25 fire safety citations on file: 15 on March 10, 2026, 10 on June 17, 2024.
Every fire safety citation25 citations
- 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 · March 10, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 10, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 10, 2026 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 10, 2026 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · March 10, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 17, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 17, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · June 17, 2024 · Corrected (the home has a date of correction)