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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
5E
0F
Potential for minimal harm
0A
4B
0C
April 16, 2026Standard inspection · 2 citations
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days in 1 of 5 residents reviewed for unnecessary medications (Resident identifier is #11).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure medications were administered in accordance with physician orders. This failure resulted in multiple insulin administration errors for 1 of 1 resident reviewed for insulin. (Resident identifier is #33.)
February 21, 2025Standard inspection · 2 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate was less than 5 percent (%) for 11 of 35 medication administrations observed. (Resident identifiers are #38)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to meet professional standards for 1 of 4 nursing staff observed for medication administration and 1 of 2 residents reviewed for pain in a final sample of 16 residents (Resident identifiers are #164 and #214).
January 19, 2024Standard inspection, Complaint inspection · 10 citations
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that long term care residents were seen face to face by a physician at least once every 60 days for 2 out of 2 residents reviewed for physician visits in a final sample of 22 residents (Resident Identifiers are #22 and #42).
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs for 12 of 30 days reviewed (Resident Identifiers are #3, #10, #13, #15, #19, #21, #22, #29 #43, #46, and #211).
- E
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, it was determined that the facility failed to monitor medication temperatures to ensure safe temperature controls in 3 out of 4 medication room refrigerators observed.
- E
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, it was determined that the facility failed to monitor food temperatures to ensure proper preparation.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that residents' needs were timely addressed for 1 of 3 closed records reviewed (Resident Identifier is #111).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete a performance review of nurse aides at least every 12 months for 1 of 1 Licensed Nursing Assistant (LNA) reviewed for annual performances.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that any irregularities reported in residents' drug regimen review were acted upon by the attending physician for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier is #40).
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that the required 12 hours of in-service training was completed for 1of 1 (Licensed Nursing Assistant (LNA)) reviewed for required in-service training.
- B
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, it was determined that the facility failed to provide the resident or the resident's representative with a written notice of transfer/discharge and also failed to send a copy of the written notice of transfer/discharge to the Long-Term Care (LTC) Ombudsman for 3 of 3 resident discharged records reviewed in a final sample of 22 residents (Resident identifiers are #28, #59, and #161).
- B
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, it was determined that the facility failed to ensure that residents' records were complete and accurate for 2 residents in a final sample of 22 residents (Resident Identifiers are #59 and #111).
November 1, 2023Complaint inspection · 2 citations
- B
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that residents had access to their funds on an ongoing basis for 1 of 4 residents reviewed for Resident Funds (Resident identifier is #1).
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflect the resident's smoking status for 4 of 4 residents reviewed for smoking (Resident Identifiers are: #1, #2, #3, #4). Finding Include: Interview on 11/1/23 at 9:20 a.m. with Staff A (Unit Manager) revealed that Residents #1, #2, #3, and #4 were smokers. Resident #2 Interview on 11/1/23 at 9:45 a.m. with Resident #2 revealed that Resident #2 has been a smoker since his admission to the facility 11/25/21. Review on 11/1/23 of Resident #2's care plan dated 2/14/22 with a target date of 11/20/23 revealed a smoking plan of care. Review on 11/1/23 of Resident #2's Annual MDS with an Assessment Reference Date (ARD) of 11/30/22 revealed that under Section J1300 Current Tobacco Use was coded as 0 or No. [...]
Fire safety inspections
9 fire safety citations on file: 5 on April 16, 2026, 3 on February 21, 2025, 1 on January 19, 2024.
Every fire safety citation9 citations
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 16, 2026 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · April 16, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 16, 2026 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 16, 2026 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · February 21, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 21, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 21, 2025 · Corrected (the home has a date of correction)
- B
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 19, 2024 · Corrected (the home has a date of correction)