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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
3D
2E
0F
Potential for minimal harm
0A
0B
0C
May 20, 2026Standard inspection · 0 citations
April 17, 2025Standard inspection, Complaint inspection · 6 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, observations, and Medical Director, family member, and staff interviews, the facility failed to utilize a sit to stand lift per manufacturer's instructions which resulted in the sling slipping up and causing extensive bruising to Resident #399 under the resident's left arm, left side, and across her breast. Resident #399 was prescribed an anticoagulant (blood thinner) daily for atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots in the heart). The following day Resident #399 experienced a syncopal episode (temporary loss of consciousness due to a sudden, temporary drop in blood flow to the brain) and when assessed it was noted she had low blood pressure and an irregular pulse. [...]
- E
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 record review and interviews with the Pharmacy Consultant, Medical Director and staff, the facility failed to have an adequate clinical indication for the use of an antipsychotic medication (Resident #42). This was for 1 of 5 residents whose medications were reviewed.
- E
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to verify that 1 of 5 nurses, Nurse #4, had a valid, non-expired nursing license. The facility was responsible for ensuring that all nursing staff employed had current licenses.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, record review, and staff and emergency contact interviews, the facility failed to identify hearing aides were missing and investigate whether an appointment was needed to maintain hearing abilities for a resident with reported hearing difficulties for 1 of 1 resident reviewed for hearing (Resident #16).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, and resident, staff, Medical Director, Pharmacy Consultant and Resident Representative interviews, the facility failed to ensure a resident was free of significant medication error when Resident #14 received 2 units of Humalog insulin (short acting insulin/antidiabetic medication). Humalog insulin was not prescribed to Resident #14. On 10/26/25 Resident #14 was given Humalog insulin medication prescribed to another resident. This deficient practice affected 1 of 1 resident reviewed for significant medication error.
- 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 staff interviews, the facility failed to ensure a medical record was accurate regarding the Treatment Administration Record (TAR). This was for 1 of 1 resident in the area of hearing aid application (Resident #16) who was reviewed for medical record accuracy.
December 21, 2023Standard inspection · 0 citations
Fire safety inspections
16 fire safety citations on file: 2 on April 17, 2025, 8 on December 21, 2023, 6 on August 5, 2022.
Every fire safety citation16 citations
- D
Install proper backup exit lighting.
K 281 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 21, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 21, 2023 · 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 · December 21, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 5, 2022 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 5, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 5, 2022 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 5, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 5, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 5, 2022 · Corrected (the home has a date of correction)