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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
15D
2E
0F
Potential for minimal harm
0A
0B
0C
February 20, 2026Standard inspection · 5 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure active diagnoses were included on a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS assessments. (Resident 4)
- 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 interview and record review, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for 1 of 1 resident reviewed for care plans. (Resident 4)
- 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 order was followed according to the prescribed parameters and an Abnormal Involuntary Movement Scale (AIMS) assessment was completed for 3 of 7 residents reviewed for quality of care. (Resident 1, 37 and 4)Findings Include:1. The clinical record for Resident 1 was reviewed on 2/17/26 at 9:46 a.m. The diagnoses included, but were not limited to, sepsis, cardiomyopathies, combined systolic (congestive) and diastolic (congestive) heart failure, and hypertensive heart disease with heart failure. A care plan, dated 1/6/26, indicated Resident 1 had an impairment in functional status related to hypertension and cardiomyopathy. Interventions included, but were not limited to, administer medications as ordered. [...]
- 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, interview and record review, the facility failed to ensure controlled substance medications were destroyed when compromised or no longer in use for 1 of 2 medication carts reviewed for medication storage. (100 hall front cart)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment correctly, isolation signage was posted, orders were followed and medication was destroyed after being dropped for 3 of 4 residents reviewed for infection control. (Resident 3, 74 and 32).
August 27, 2025Complaint inspection · 1 citation
- 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 was assessed timely after an unwitnessed fall and to ensure monitoring and measurements of a bruise which resulted from the fall was completed for 1 of 3 residents reviewed for quality of care. (Resident C)
March 18, 2025Standard inspection · 3 citations
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents and resident's representatives were given notification in writing of the reason for the resident's transfer and discharge to the hospital for 5 of 5 residents reviewed for hospitalization or discharge. (Resident 36, 28, 30, 18 and 74)
- E
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 wrote3. The clinical record for Resident 30 was reviewed on 3/17/25 at 10:02 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, pulmonary embolism, hypertension, congestive heart failure, obesity, cerebrovascular accident, hemiplegia, hemiparesis, transient ischemic attack, and muscle weakness. A nursing progress note, dated 1/18/25 at 12:25 p.m., indicated the resident was sent to the emergency room for evaluation. A nursing progress note, dated 1/19/25 at 4:08 a.m., indicated the resident had been admitted to the hospital for pulmonary embolism and right heart strain. During the clinical record review, there was no documentation found to indicate the resident and resident's representative were given information in writing regarding the facility's bed hold policy, including the facility's charge to hold a bed. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered at the correct physician ordered flow rate for 2 of 4 residents reviewed for respiratory care. (Resident 34 and 37)
February 14, 2024Standard inspection · 8 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure significant weight changes were identified and timely interventions were implemented for 2 of 5 residents reviewed for changes in weight (Resident 109 and 19). This deficient practice resulted in Resident 109 experiencing two events of significant weight gain which required hospitalization for fluid overload and Resident 19 experiencing significant weight loss which required hospitalization for altered mental status and dehydration.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident had a self medication administration assessment and an order for the resident to keep the medication at the bedside prior to leaving eye drops in the room for the resident to self administer for 1 of 1 residents observed for medication administration. (Resident 159)
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, interview, and record review, the facility failed to observe and evaluate for appropriate and safe use of fall prevention interventions for 1 of 4 residents reviewed for accidents (Resident 48).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's facial hair was shaved for 1 of 2 residents reviewed for activities of daily living (Resident 11) and failed to provide denture care for 1 of 2 residents reviewed for activities of daily living (Resident 108).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure there was a physician's order for the use of oxygen and failed to ensure the physician's order was followed for 1 of 1 residents reviewed for oxygen use (Resident 30).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure there was a physician's order for the use of oxygen and the physician's order was followed for 1 of 1 residents reviewed for oxygen use (Resident 30).
- 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 as needed (PRN) anxiety medications were prescribed only for 14 days and reviewed for the need to continue use for 1 of 5 resident reviewed for unnecessary medications (Resident 15).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Electronic Health Record (EHR) contained accurate information about a resident's advanced directives for 1 of 1 resident reviewed for advanced directives (Resident 55).
December 1, 2023Complaint inspection · 1 citation
- 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 there was accurate documentation of narcotic pain medication being signed out for 1 of 3 residents being reviewed for accurate documentation. (Resident B)
Fire safety inspections
12 fire safety citations on file: 6 on February 20, 2026, 3 on March 18, 2025, 3 on February 14, 2024.
Every fire safety citation12 citations
- F
Provide properly protected cooking facilities.
K 324 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2026 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 20, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 18, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 18, 2025 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · March 18, 2025 · Corrected (the home has a date of correction)
- E
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 · February 14, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · February 14, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 14, 2024 · Corrected (the home has a date of correction)