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
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
16D
3E
1F
Potential for minimal harm
0A
0B
0C
June 25, 2026Standard inspection, Complaint inspection · 11 citations
- F
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, staff interview, medical record review, review of manufacturer instructions, and review of facility policy, the facility failed to store and manage medications safely, including improper dating, disposal, labeling of multi-does and insulin medications, and leaving medication carts unsecured. This had the potential to affect all 119 residents residing in the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, review of the mechanical lift and mechanical lift slings manufacturer's instructions, observation, resident and staff interviews, and policy review, the facility failed to ensure residents were transferred safely following physician orders and ensure staff were monitoring the mechanical lift slings for signs of damage. This had the potential to affect 39 residents (#4, #6, #7, #8, #9, #11, #12, #15, #22, #32, #33, #34, #38, #42, #45, #48, #51, #54, #59, #60, #65, #72, #74, #75, #76, #77, #88, #90, #94, #95, #99, #100, #104, #107, #108, #109, #112, #118, and #119) who the facility identified as requiring the use of a mechanical lift for transfers. The facility census was 119.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on review of facility menus, record review, observations, and staff interviews, the facility failed to serve the correct food portions of pureed foods to the residents. This affected seven (#22, #32, #45, #60, #72, #74, and #104) of seven residents who were ordered pureed diets. The facility census was 119.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on medical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure a resident was treated with dignity when his wheelchair safety harness was visibly soiled. This affected one resident (#65) of three residents reviewed for dignity. The facility census was 119.
- 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 medical record review, staff interview, and policy review, the facility failed to ensure the resident's advanced directives were accurate in the paper and electronic medical record (EMR). This affected one (#86) of three residents reviewed for advanced directives. The facility census was 119.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to provide a resident who was dependent on staff for showers/bathing received routine showers/bathing. This affected one (#64) of three residents reviewed for activities of daily living. The facility census was 119.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, observation, resident interview, and staff interview, the facility failed to provide a resident with a urinary catheter with the means to secure the catheter to prevent possible dislodgement. This affected one (#107) of three residents reviewed for catheter. The facility census was 119.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observations, staff interviews, and policy review, the facility failed to ensure oxygen was administered per physician orders. This affected two residents (#60 and #94) of three residents reviewed for oxygen administration. The facility census was 119.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on medical record review, observation, staff interview, and review of facility documents, the facility failed to ensure alternatives to bed rails were attempted and failed to provide ongoing monitoring and supervision for a resident who utilized a bed rail. This affected one (Resident #1) of one resident reviewed for bed rail safety. The facility census was 119.
- 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, observation, staff interview, and policy review, the facility failed to ensure accurate accountability of controlled substances by maintaining controlled substance records that reconciled with the actual quantity of medication on hand. This affected one (Resident #87) of one resident reviewed for control substance records.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) during high-contact resident care activities for residents who had physician orders for EBP. This affected two (#51 and #74) of two residents reviewed for EBPs. The facility identified 35 residents with physician orders for EBP. The facility census was 119.
April 30, 2026Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, hospital record review, resident, family, staff, physician, and agency staff interviews, review of staff statements, and review of the facility policy, the facility failed to ensure safe mechanical lift transfers and further failed to adequately assess, timely notify the physician and resident representative, address resident pain, and conduct a thorough investigation following a fall from a mechanical lift. This resulted in Actual Harm to Resident #36 when on the morning of 04/22/26, the resident fell during a mechanical lift transfer and was found to have sustained a displaced fracture of the distal femur and a distal fifth metacarpal fracture of the left hand. Facility staff failed to thoroughly assess the resident at the time of the incident and the resident cried out in pain throughout the night. [...]
March 16, 2023Standard inspection · 2 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure nutritional interventions were implemented per physician order and the plan of care, for residents identified at nutritional risk. This affected two (#39 and #52) of three residents reviewed for nutrition. The facility census was 95.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to maintain accurate medical records regarding documentation for nutritional supplements. This affected one (#52) of two residents reviewed for nutrition. The facility census was 95.
February 6, 2020Standard inspection · 7 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, review of dietary menus, review of dietary spreadsheets, and staff interviews, the facility failed to serve the identified portion sizes of pureed chicken to 12 residents (#4, #5, #9, #16, #23, #57, #59, #65, #76, #80, #93 and #94) who received pureed diets. The facility census was 119.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on medical record review, observation, family interview, staff interview, and review of facility policy, the facility failed to ensure call lights were in reach for three (#45, #57, #65) of 24 residents reviewed for accommodation of needs. The facility census was 119.
- 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 observations, medical records review, resident interview, and staff interview, the facility failed to honor resident choice on roommates and who to eat meals with for two (#62 and #85) of 24 sampled residents. The facility census was 119.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on medical record review, review of facility policy, family interview, review of financial records, and staff interview, the facility failed provide the notice of bedhold policy upon discharge to the hospital for one (#166) of three residents reviewed for hospitalization. The facility census was 119.
- 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 medical record review, resident interview, family interview, and staff interviews, the facility failed to ensure residents were invited to participate in their care planning meetings. This affected one (#166) of four residents reviewed for participation in care planning. The facility census was 119.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, medical record review, and staff interviews, the facility failed to follow physician orders for the application of a boot to the lower extremity for one (#1) of five residents reviewed for skin conditions. The facility census was 119.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased of review of a nurse's note, review of a vision provider note, review of an Eye Glass Tracker form, review of a Vision Care form, staff interviews, and review of facility policy, revealed the facility failed to timely follow up with a vision care provider regarding ordered eye glasses not yet received. This affected one (#91) of one resident reviewed for vision care services. The facility census was 119.
Fire safety inspections
10 fire safety citations on file: 3 on June 25, 2026, 2 on March 16, 2023, 5 on February 6, 2020.
Every fire safety citation10 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 25, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 25, 2026 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · June 25, 2026 · Corrected (the home has a date of correction)
- 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 16, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 16, 2023 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · February 6, 2020 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 2020 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 6, 2020 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · February 6, 2020 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 6, 2020 · Corrected (the home has a date of correction)