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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
4E
1F
Potential for minimal harm
0A
0B
0C
June 26, 2026Standard inspection, Complaint inspection · 16 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, resident and staff interviews, and document review, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 3 of 3 residents (#73, #77, and #79) observed for dignity. This deficient practice had the potential for residents to experience embarrassment and low feelings of self-worth.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 4 of 4 residents (#4, #10, #19, and #44) reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when their medications were not administered according to the physician's order.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals and follow proper cleaning of medical equipment and handling of linens. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on resident and staff interviews, record review, and policy review it was determined the facility failed to ensure resident's preference for bathing schedule was honored. This was true for 1 of 23 residents (Resident #5) reviewed for choices. This deficient practice had the potential for residents to experience a decreased sense of well-being, lack of self-worth, and frustration when their preference for bathing was not accommodated.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure as needed (PRN) psychotropic drugs were limited to 14 day use. This was true for 1 of 1 Resident (Resident #4) reviewed for psychotropic medication use. This failure created the potential for residents to be subjected to unnecessary psychotropic medication use.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a written notice of transfer and bed hold policy was provided to the resident or their representative when residents were transferred to the hospital. This was true for 1 of 2 residents (Resident #12) reviewed for transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility.
- 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 document review, staff interview, and policy review it was determined the facility failed to provide a resident's baseline care plan to the resident or his/her representative for 1 of 1 resident (Resident #73) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan.
- 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, policy review, and staff interview, it was determined the facility failed to ensure residents maintained a person-centered comprehensive care plan. This was true for 1 of 1 resident (Resident #76) whose record was reviewed for comprehensive care plans. This created the potential for harm when staff were not informed of person-centered care and treatment interventions.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given treatment and services to maintain or improve their ability to carry out activities of daily living (ADLs). This was true for 1 of 1 resident (Resident #12) reviewed for decline in ADLs without services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure that parenteral/IV fluids were administered consistently with professional standards of practice. This occurred for 1 of 2 residents (Resident #42) reviewed for IV therapy.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.
- 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 record review, policy review, and staff interview, it was determined the facility failed to ensure residents were monitored appropriately for medication. This was true for 1 of 2 residents (Resident #4) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring.
- 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 observation, policy review, and staff interviews, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents and were destroyed in a timely manner when they were discontinued to prevent unauthorized access and potential diversion. This was true for 1 of 2 medication storage rooms inspected and 1 of 4 medication carts observed.
- D
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, policy review, and review of the FDA Food Code, the facility failed to ensure food items were dated and labeled. These deficient practices had the potential to impact all residents who received food brought in by family or visitors. This placed residents at risk for potential use of spoiled foods and adverse health outcomes including food-borne illnesses.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview it was determined the facility failed to ensure trash was contained in the facility's dumpsters with closed lids for two of two outside trash dumpsters and the kitchen garbage cans were properly closed with tight fitting lids. This failed practice created the potential for insect and pest infestation.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, record review, and policy review, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 3 of 3 Residents (#76, #77, and #79) reviewed for oxygen administration orders. This deficient practice created the potential for harm should inappropriate care and/or treatment be provided based on inaccurate information in the residents' clinical record.
May 1, 2025Standard inspection, Complaint inspection · 7 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, Hoyer lift manual review, interview, and review of the facility's investigation report, it was determined the facility failed to ensure resident safety during Hoyer lift transfers. This was true for 1 of 8 residents (Resident #174) whose record was reviewed for falls. This resulted in harm to Resident #174 when a proper Hoyer lift transfer was not provided.
- 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 the FDA Food Code, observation, and interview, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for a) 2 of 5 residents (#22 and #45) who had uncovered urinary drainage bags and b) 1 of 19 Residents (Resident #50) who was addressed by a room number not her name. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined the facility failed to ensure 1 of 1 resident (Resident #28), was assessed and evaluated for cognitive and physical ability to self-administer medications. This failure created the potential for adverse outcomes if Resident #28 self-administered medication inappropriately.
- 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 observation, record review, and interview, it was determined the facility failed to ensure a baseline care plan was developed and implemented to include resident sleep apnea equipment needs. This was true for 1 of 19 residents (Resident #164) reviewed for baseline care plans. This failure placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plans.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 4 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.
- 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 observations and staff interviews, it was determined the facility failed to ensure medications and lab draw supplies were properly stored in a locked compartment, and biologicals were labeled when opened. These deficient practices created the potential for undetected access to medications by unauthorized personnel and use of expired biologicals.
July 11, 2024Standard inspection · 4 citations
- E
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 observation, policy review, review of Resident Council minutes, review of facility grievances, and resident and staff interview, it was determined the facility failed to ensure resident meals were served following the facility's designated meal schedule. This was true for 4 of 5 residents (#20, #29, #30, and #111) interviewed for concerns with food. This failure had the potential to impact residents in the facility who were at risk for nutritional compromise and had the potential to harm residents if they experienced hunger, low blood sugar levels, or did not receive adequate nutritional support for healing or weight loss.
- 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, policy review, staff interview, it was determined the facility failed to ensure a resident's MDS assessment accurately reflected their status at the time of the assessment (Resident #30) and a resident's comprehensive MDS assessment was completed prior to the required completion date (Resident #211). This was true for 2 of 2 residents whose MDS assessments were reviewed. This failure created the potential for harm if care decisions were based upon inaccurate or lack of information.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review. policy review, and staff interview, the facility failed to ensure residents received meal assistance or were provided meal recommendations. This was true for 2 of 5 residents (#29 and #39) reviewed for nutritional status. This failure created the potential for harm if residents became dehydrated and they experienced unplanned weight loss.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, policy review, record review, and staff interview, the facility failed to ensure enhanced barrier precautions were followed. This was true for 1 of 1 resident (Resident #8) reviewed. This failure increased the risk of spreading multidrug resistant organisms.
Fire safety inspections
11 fire safety citations on file: 1 on June 26, 2026, 7 on May 1, 2025, 3 on July 11, 2024.
Every fire safety citation11 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · June 26, 2026 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 1, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · May 1, 2025 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · July 11, 2024 · Corrected (the home has a date of correction)