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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
14D
1E
1F
Potential for minimal harm
0A
0B
0C
June 22, 2026Complaint inspection · 3 citations
- G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of the facility's policy, clinical records, hospital records, and interviews with staff, nurse practitioner, resident, and family, it was determined the facility failed to timely notify and report accurate information of a resident's change in condition to the physician for one of two residents reviewed (Resident 1). This failure resulted in actual harm of the resident when they were hospitalized , requiring intubation, mechanical ventilation, and ICU (Intensive Care Unit) admission for monitoring. Findings Include: Review of the facility's policy titled Resident Change in Condition Policy, last reviewed on June 2, 2025, revealed The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the family/Responsible Party will be notified as soon as the nurse has identified the change in condition. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on a clinical records review, interview with staff and Nurse Practitioner (NP), it was determined that the facility failed to practice professional standards of nursing by performing a procedure without a physician's order for one of two residents reviewed (Resident 1).
- 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 clinical records review and staff interviews, it was determined that the facility failed to provide consistent monitoring of the resident's urine output and perform a procedure with a physician's order for one of the two residents reviewed (Resident 1).
April 30, 2026Standard inspection · 3 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 observations and staff interview, it was determined that the facility failed to ensure that food stored in the walk-in fridge and freezer were properly stored to prevent contamination and ensure safe storage in accordance with professional standards for food service safety in the main kitchen.
- 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 observations, clinical records review and staff interviews, it was determined that the facility failed to ensure care plans were updated for appropriate wheelchair positioning for one of eight residents reviewed (Resident 9). Findings revealed:A review of Resident 9's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 7, 2025, revealed resident had a diagnosis of Alzheimer's' Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Seizure disorders (A chronic neurological condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), and Contracture-knee (A permanent, stiffening of muscles, tendons, ligaments or skin, causing restriction in joint movement). [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical records review, and staff interview, it was determined that the facility failed to ensure physicians were notified and an intervention was put in place for a significant weight loss for two of two residents reviewed (Resident 27 and 83).
March 7, 2025Standard inspection · 8 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased upon clinical record review and interview, it was determined the facility failed to ensure residents' physician was notified regarding a resident and failed to ensure residents' physician was notified of a significant weight loss for two of two residents reviewed (Resident 72 and Resident 104).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on clinical record reviews, interviews with staff and residents, it was determined that the facility failed to conduct an accurate comprehensive assessment for one of 32 residents reviewed. (Resident 51)
- 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, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of two residents reviewed regarding oxygen use. (Resident R6)
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on closed clinical record review and interviews with staff, it was determined the facility failed to ensure discharge instructions included all necessary information, including a recapitulation of stay, resident status, medication reconciliation, living arrangements, follow-up care and individualized care instructions, for a one of three closed records reviewed (Resident 111).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased upon clinical record review and interview, it was determined the facility failed to ensure a fluid restriction, ordered by resident's physician, was monitored for one of one resident reviewed (Resident 99).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased upon clinical record review and interview, it was determined the facility failed to ensure adequate monitoring of a resident with a significant weight loss (Resident 104).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased upon observations, clinical record review and staff interviews, it was determined that the facility failed to ensure fluid restrictions were followed for one of one dialysis resident reviewed. (Resident 16).
- 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 upon clinical record review, it was determined the facility failed to monitor for effectiveness or side effects of anti-depressant medication for one of five residents reviewed (Resident 93).
April 5, 2024Standard inspection · 3 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, it was determined that the facility failed to provide privacy and confidentiality of residents ' personal information on two of four nursing units (South and East).
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 109).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on a comprehensive review of clinical records, observations, and interviews with residents and staff, it was determined that the facility failed to consistently implement and maintain infection control practices, thereby risking the potential spread of infection for one resident requiring contact precautions (a method to prevent the transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment) out of 32 residents sampled (Resident 90).
Fire safety inspections
11 fire safety citations on file: 2 on April 30, 2026, 4 on March 7, 2025, 5 on April 5, 2024.
Every fire safety citation11 citations
- E
Use approved construction type or materials.
K 161 · April 30, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 30, 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 7, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 7, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · March 7, 2025 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 5, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 5, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 5, 2024 · Corrected (the home has a date of correction)
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · April 5, 2024 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · April 5, 2024 · Corrected (the home has a date of correction)