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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
2E
0F
Potential for minimal harm
0A
1B
0C
May 13, 2026Complaint inspection · 2 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to ensure medications were administered in accordance with physician's orders and accepted standards of practice for four (4) of 4 residents observed during medication administration observation on one (1) of two (2) halls. The facility's medication error rate was 100%. This had the potential to affect residents through delayed medication administration. Resident #1, Resident #2, Resident #3 and Resident #4. Cross Reference F760Findings Include: Review of the facility policy Medication Errors dated 09/09/25 revealed Policy Explanation and Compliance Guidelines .2. [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to administer physician ordered significant medications timely for one (1) of four (4) medication carts observed. Cross Reference F759Findings Include:Review of the facility policy Medication Errors dated 09/09/25 revealed, It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors .Resident #1On 05/13/26 at 12:15 PM an observation and interview with Resident # 1 revealed that her medications were late most of the time. She stated, If you consider eleven o'clock, one o'clock or two o'clock on time, then I'm getting them on time. She revealed that she had mentioned it before, but it didn't do any good. [...]
October 27, 2025Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from exploitation and misappropriation of personal funds for one (1) of three (3) residents reviewed for misappropriation of property (Resident #1).
August 7, 2025Standard inspection, Complaint inspection · 6 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview, record review, and the facility's policy review, the facility failed to ensure that the residents or their representatives were involved in the care planning process for two (2) of 28 residents reviewed for care planning. Residents # 21 and 87.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) assessments within the timeframes required by the Resident Assessment Instrument (RAI) User's Manual for (3) three of 33 MDS assessments reviewed. Residents #39, 69, and 95. Findings Include Record review of the facility policy titled MDS 3.0 Completion revealed: Policy Explanation of Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident’s functional capacity, using the RAI specified by the State. 2. Types of Assessments…b. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to complete and transmit the Quarterly and Discharge Minimum Data Set (MDS) assessments within the required time frame for 10 of 33 MDS assessments reviewed. Residents # 24, #35, #58, #63, #82, #90, #105, #107, #108 and #118. Findings Include Record review of the facility policy titled MDS 3.0 Completion date implemented 2/01/2025 revealed: Policy Explanation of Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident’s functional capacity, using the Resident Assessment Instrument (RAI) specified by the State. 2. Types of Assessments…e. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one (1) of 33 MDS assessments reviewed. Resident #122. Findings Include Record review of the facility policy, “Minimum Data Set (MDS) 3.0 Completion” revealed “Policy Explanation of Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident’s functional capacity, using the Resident Assessment Instrument (RAI) specified by the State. Record review of the Progress Note for Resident #122, dated 7/17/25, revealed that the resident was discharging home. [...]
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure residents were free from misappropriation of medications for two (2) of eight (8) residents reviewed for drug diversion (Residents #14 and #42).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors for six (6) of 29 residents reviewed for medication administration. (Residents #12, #42, #79, #84, #108, and #111)
March 26, 2025Complaint inspection · 2 citations
- 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 resident and staff interviews, record review and facility policy review the facility failed to implement a comprehensive care plan for residents with personal hygiene needs for two (2) of six (6) sampled residents. Resident #5 and Resident #6. Findings Include: Record review of the undated facility policy, Comprehensive Care Plans revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . Resident #5 On 03/25/25 at 11:30 AM, an interview with Resident #5 revealed she did not get her shower on Saturday, 03/22/25, and she hadn't had a shower since last Thursday, 03/20/25. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff and resident interviews, record review and facility policy review the facility failed to provide care to maintain personal hygiene for two (2) of six (6) residents reviewed for Activities of Daily Living (ADL) care. Resident #5 and Resident #6. Findings Include: Record review of the undated facility policy, Activities of Daily Living (ADL's) revealed under Policy Explanation and Compliance Guidelines .3. The resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene Resident #5 An interview on 03/25/25 at 11:30 AM with Resident #5 revealed that the care at the facility wasn't perfect but was okay. Resident #5 revealed that she did not get her shower on Saturday, 03/22/25, and she hadn't had a shower since last Thursday, 03/20/25. [...]
August 20, 2024Complaint inspection · 2 citations
- J
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 interviews, record review, and facility policy review, the facility failed to implement effective comprehensive care plan interventions for a resident who was at risk for wandering and elopement for one (1) of three (3) residents at risk for wandering and elopement. Resident #1 Resident #1 was left on the front patio, where she subsequently exited the premises unnoticed and unsupervised. The resident was later found at a grocery store approximately 0.3 miles from the facility. Video surveillance footage revealed Resident #1 left the facility at 4:05 PM and was located at the grocery store at 4:25 PM. The facility's failure to implement effective care plan interventions placed Resident #1, and all other residents at risk for wandering and elopement, in a situation that was likely to cause serious harm, serious injury, serious impairment or death. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff and resident interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk from leaving the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed for wandering. Resident #1. The facility's failure to provide supervision resulted in Resident #1 being left on the front patio, where she subsequently exited the premises unnoticed and unsupervised. The resident was later found at a grocery store approximately 0.3 miles from the facility. Video surveillance footage revealed Resident #1 left the facility at 4:05 PM and was located at the grocery store at 4:25 PM. [...]
March 28, 2024Standard inspection, Complaint inspection · 4 citations
- 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 observations, staff interviews, record review and facility policy review the facility failed to implement a care plan related to nail care for one (1) of nineteen residents reviewed. Resident #33. Findings Include: Review of the facility policy titled, Comprehensive Care Plans with an implemented date of 12/2022 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #33's Care Plan dated 10/11/21 revealed that she had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and dementia. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, staff interviews, record review and facility policy review the facility failed to provide nail care for a resident who was dependent on staff for Activities of Daily Living (ADL) Care for one (1) of nineteen residents reviewed. Resident #33. Findings Include: Record review of the undated facility policy on Nail Care revealed, .Policy Explanation and Compliance Guidelines .2. Routing cleaning and inspection of nails will be provided during ADL (Activities of Daily Living) care on an ongoing basis. 3. Routine nail care, to include trimming and filing, will be provided regularly. 4. Principles of nail care: a. Nails should be kept smooth to avoid skin injury . On 03/26/24 at 10:30 AM, an observation of Resident #33 revealed her sitting in her wheelchair at a table in the A-Wing Day Room and her fingernails on both hands were long and jagged. [...]
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to accurately code a residents Minimum Data Set (MDS) Assessment for (1) one of 19 resident assessments reviewed. (Resident #55)
- D
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 staff and resident interviews, record review, and facility policy review the facility failed to properly store drugs which were delivered by the pharmacy in one (1) of four (4) medication carts in the facility. Based on the facility's implementation of corrective actions on 12/13/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 12/18/23, prior to the SA's first entrance on 3/26/24. Findings Include: Record review of the undated facility policy titled Medication Storage revealed under Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biological's will be stored in locked compartments 2. Narcotics and Controlled Substances: a. Schedule II drugs and back-up stock of Schedule III, IV, and V medications are stored under double-lock and key. [...]
March 2, 2023Standard inspection · 4 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review, staff interview and facility policy review the facility failed to submit a Change in Status form for a resident with a new diagnosis of anxiety disorder and ensure the Resident was evaluated for a Preadmission Screening and Resident Review (PASARR) Level II for one (1) of two (2) resident reviewed for PASARR. Resident #62.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on staff interviews, record review, and policy review, the facility failed to develop a Baseline Care Plan within 48 hours of admission for one (1) of 20 residents reviewed.
- 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 record review, staff interviews, and facility policy review, the facility failed to develop a Comprehensive Person-Centered Care Plan for a resident with a new diagnosis of Anxiety disorder, for 1 (one) of 20 residents reviewed for care plans.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide the necessary assessment and treatment to promote the healing of a pressure ulcer for one (1) of three (3) residents reviewed for pressure ulcers. Resident # 136.
Fire safety inspections
2 fire safety citations on file: 1 on August 7, 2025, 1 on March 28, 2024.
Every fire safety citation2 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 28, 2024 · Corrected (the home has a date of correction)