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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
2E
1F
Potential for minimal harm
0A
0B
0C
March 31, 2026Standard 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 ensure the food preparation area did not contain employee drinks and frozen food was sealed in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 65 of 65 residents who received food from the kitchen.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's orders were followed, a medication was administered according to the ordered parameters, and to obtain an admission weight for 3 of 3 residents reviewed for quality of care. (Resident 6, 17 and 44)Findings Include: 1. The clinical record for Resident 6 was reviewed on 3/25/26 at 10:59 a.m. The diagnoses included, but were not limited to, hypotension, vitamin deficiency, acute kidney failure, and iron deficiency anemia. A care plan, dated 3/19/26, indicated the resident had a potential for cardiovascular distress related to the diagnosis of hypotension. Interventions included, but were not limited to, administer medications as ordered. [...]
August 22, 2025Complaint inspection · 1 citation
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's discharge paperwork provided to the receiving facility was accurate for 1 of 3 residents reviewed for discharge. (Resident C)
May 19, 2025Standard inspection · 7 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were served their meals together, staff were seated while eating with the residents, and a resident was able to complete their meal before being removed from the dining room for 1 of 2 dining rooms reviewed for dignity. (the legacy dining room)
- 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 interview and record review, the facility failed to ensure a do not resuscitate (DNR) order was updated when received for 1 of 1 resident reviewed for advanced directives. (Resident 21) The deficient practice was corrected on 4/28/25, prior to the start of the survey, and therefore was past noncompliance.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to ensure the residents were issued SNF ABN's (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) for 2 of 3 residents reviewed for beneficiary notification. (Resident 1 and 20) The deficient practice was corrected on 2/13/25, prior to the start of the survey, and therefore was past noncompliance.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was correctly coded for 1 of 1 resident reviewed for resident assessments. (Resident 49)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure vital signs and neurological assessments were documented for 1 of 1 resident reviewed for assessments. (Resident 70) The deficient practice was corrected on 5/10/25, prior to the start of the survey, and therefore was past noncompliance.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's diagnoses in the medical record were accurate and correct for 1 of 1 resident reviewed for documentation. (Residents 49)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to ensure the policy and procedure related to administering two (2) step Mantoux skin tests for tuberculosis were followed for 4 of 5 employees reviewed for infection control. (QMA 6, QMA 7, CNA 8 and CNA 9)
November 14, 2024Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received medications per the physician's order for 1 of 1 resident reviewed for quality of care. (Resident H) This deficient practice was corrected on 6/10/24, prior to the start of the survey, and was therefore past noncompliance.
- D
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 ensure medications were documented as given, medications were disposed of properly, narcotic medication logbooks reflected the medication given to residents and medication records were reconciled for 3 of 5 medication carts reviewed. This deficient practice was corrected on 6/10/2024, prior to the start of the survey, and was therefore past noncompliance.
April 29, 2024Standard inspection · 7 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications within the ordered time frame, assess and accurately document a resident's dental status and communicate with hospice and provide a positioning chair to meet the residents care planned needs for 6 of 6 residents reviewed for quality of care. (Residents 40, 47, 1, 20, 46 and 27)
- 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 interview and record review, the facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for 1 of 1 resident reviewed for comprehensive care plans. (Resident 29).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure post fall interventions were evaluated for effectiveness and a rationale was documented prior to removing the interventions from the comprehensive care plan for 2 of 3 residents reviewed for accidents. (Resident 23 and 54)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident on a fluid restriction was monitored for 1 of 1 resident reviewed for a fluid restriction related to dialysis. (Resident 47)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to include monitoring for seizure medication side effects and seizure activity and to review a resident's history for 1 of 5 residents reviewed for unnecessary medications. (Resident 29).
- 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 the assessments for side effects for antipsychotic medications were completed timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 54)
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was free of strong odors, the walls, doors, and carpet were maintained, and the trash was disposed of in 2 of 3 units observed for environment. (200 hall and 100 hall)
October 5, 2023Complaint inspection · 1 citation
- D
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 protect a resident from misappropriation of medication when a medication card for narcotics (30 tablets) was discovered to be missing from the facility's double locked medication cart for 1 of 1 resident reviewed for misappropriation of property. (Resident G) The deficient practice was corrected on 9/21/23, prior to the start of the survey, and was therefore past noncompliance.
Fire safety inspections
6 fire safety citations on file: 2 on March 31, 2026, 3 on May 19, 2025, 1 on April 29, 2024.
Every fire safety citation6 citations
- F
Conduct testing and exercise requirements.
E 39 · March 31, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 19, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 19, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 19, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 29, 2024 · Corrected (the home has a date of correction)