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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
22D
4E
2F
Potential for minimal harm
0A
0B
1C
April 9, 2026Standard inspection · 7 citations
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects. This affected five (#1, #11, #12, #44, and #62) of five residents reviewed for unnecessary medications. The facility census was 83.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure routine monitoring was implemented for mechanical lift slings and stand assist devices in the facility. This had the potential to affect 31 (#3, #15, #23, #34, #74, #83, #30, #43, #80, #9, #31, #63, #29, #12, #54, #61, #72, #25 #11, #13, #17, #32, #40, #44, #47, #51, #56, #61, #72, #78 and #81) that the facility identified as requiring the use of a mechanical lift slings or stand assist devices. The facility census was 83.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation, record review, staff interview, resident interview, review of manufacturer's instructions, and policy review, the facility failed to ensure mechanical lift slings were monitored and inspected per the manufacturer's instructions. This affected six (#83, #34, #15, #74, #23 and #3) and had the potential to affect 13 other residents (#11, #13, #17, #32, #40, #44, #47, #51, #56, #61, #72, #78 and #81) who the facility identified as requiring the use of a mechanical lift with slings for transfer. The facility census was 83.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed when an allegation of verbal abuse and neglect was reported. This affected one (#95) of one resident reviewed for verbal abuse and neglect. The facility census was 83.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review, staff interview, and review of the facility policy the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II following a new diagnosis of schizophrenia. This affected one (#12) of one resident reviewed for PASRR level II. The facility census was 83.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, staff interviews, and review of manufacturer guidelines, the facility failed to maintain and inspect resident transfer equipment to ensure safe transfers. This affected one (#80) of three residents reviewed for falls. The facility census was 83.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, review of the medical record, staff interview, and review of the facility policy, the facility failed to administer oxygen at the correct rate. This affected one resident (#15) reviewed for oxygen. The facility identified 11 residents (#1, #2, #13, #15, #19, #21, #40 #50, #57, #65, and #84) that required the use of oxygen. The facility census was 83.
December 8, 2025Complaint inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure accurate assessments were completed. This affected one (#65) of three residents reviewed for assessments. The facility census was 76.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteReview of the medical record for Resident #19 revealed an admission date of 07/12/25 with diagnoses including, but not limited, to seborrheic dermatitis, pressure ulcer of sacral region stage three (full thickness to fat), pressure ulcer of right buttock stage three, pressure ulcer of left buttock stage three, and paraplegia. Review of the Minimum Data Set (MDS) assessment, dated 12/02/25, revealed the resident was cognitively intact. Resident #19 had two stage three pressure ulcers that were present on admission. Review of the care plan dated 07/16/25 revealed the resident had two stage three pressure ulcers upon admission and dermatitis/fungal infection related to disease processes- paraplegic, non-compliant with care and getting up out of bed. [...]
January 6, 2025Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, resident interview, staff interview and review of facility policy the facility failed to ensure residents were free from abuse. This affected one resident (#10) of two residents reviewed for abuse. The facility census was 71.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, resident interviews, record review, and facility policy review revealed facility staff failed to report an allegation of abuse. This affected two residents (#10 and #11) of two residents reviewed for abuse. The facility census was 71.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, nurse practitioner interview, family interview, and review of facility policy revealed the facility failed to follow documented medication orders in resident records. This affected one (#84) resident of three residents reviewed for medication orders. The facility census was 71.
February 26, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, record review, review of the facility's incident reports, and review of the facility's policies, the facility failed to complete thorough investigations into wandering/elopement and fall incidents. This affected one (#11) of two residents reviewed for elopement and one (#11) of three residents reviewed for falls. The facility census was 76.
March 30, 2023Standard inspection · 12 citations
- F
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 observations, resident, resident representative, and staff interviews, record reviews, review of resident council notes, review of staff schedules, and review of facility policies, the facility failed to ensure there was sufficient nursing staff to meet the resident care needs. This affected three residents (#10, #34, and #45), and had the potential to affect all 74 residents residing in the facility.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were properly sealed, labeled, and dated in the freezer and failed to maintain the refrigerator and freezer in a sanitary condition. This had the potential to affect all 74 residents identified by the facility as reviewing food from the kitchen. The facility census was 74.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure call lights were answered timely and the residents requiring assistance had access to call lights. This affected four (#10, #22, #54, and #60) of four residents reviewed for call lights. The facility census was 74.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on medical record review, resident interview, resident representative interview ,staff interview, and review of the facility policy, the facility failed to ensure residents received their choice of showers or bed baths. This affected two (#34 and #54) of two residents reviewed for choices. The facility census was 74.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on record review, observation, staff and resident interviews, and review of facility policy, the facility failed implement the facility policy for self-medication administration for Resident #76 and further failed to obtain physician orders for the medications being self-administered by Resident #76. This affected one (Resident #76) of three residents reviewed for choices. The facility census was 74.
- 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 record review, staff and resident interview, and review of the facility policy, the facility failed to develop a comprehensive care plan to address a resident's psychosocial needs. This affected one (Resident #37) of four residents reviewed for care planning. The facility census was 74.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on medical record review, observations, resident representative and staff interview, and review of the facility policy, the facility failed to ensure a resident received activities upon the preference of the resident and choices of activities. This affected one (Resident #54) of one resident reviewed for activities. The facility census was 74.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, observation, staff and resident interviews, and review of the facility policy, the facility failed to provide care and services to assist a resident to maintain hearing devices. This affected one resident (Resident #55) of four residents reviewed for vision and hearing. The facility census was 74.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to provide timely assistance to prevent a fall with injury and failed to complete a thorough fall investigation. This affected one (Resident #45) of five residents reviewed for falls. The facility census was 74.
- 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 record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the care and management for an indwelling urinary catheter for Resident #40. This affected one (Resident #40) of three resident reviewed for having an indwelling urinary catheter. The facility identified 10 residents with indwelling or external catheters. The facility census was 74.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review, observation, staff and resident interview, and review of the facility policy, the facility failed to ensure a resident received mental health services and psychiatric services per physician orders to attain the highest practicable mental well-being. This affected one resident (Resident #37) of one resident reviewed for mental health. The facility census was 74.
- 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 record review, observation, staff interview, and policy review, the facility failed to ensure medications were dated when opened and medications were used within the expiration date, and failed to store medications in a locked compartment. This affected two of three medications carts reviewed and one of two medication storage rooms. This affected one (Resident #26) of 21 residents observed for the physical environment. The facility census was 74.
November 26, 2019Standard inspection · 4 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, staff interview, resident interview and review of the facility bowel protocol, the facility failed to monitor for bowel movements and failed to administered as needed laxatives as ordered. This affected one (Resident #26) of five residents reviewed for unnecessary medications. The facility census was 73.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on record review, interview and policy review, the failed to ensure restorative range of motion was provided as ordered. This affected one (Resident #49) of two residents reviewed for positioning. The facility identified 24 residents with restorative programs in the last 60 days. The facility census was 73.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, interview and policy review, the facility failed to monitor the dialysis vascular access for function. This affected one (Resident #26) of five residents that receive dialysis. The facility census was 73.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interview, the facility failed to ensure staffing was accurately posted in a prominent location for residents/visitors to review. This had the potentially to affect all 73 residents residing in the facility at the time of the annual survey. Facility census was 73.
Fire safety inspections
21 fire safety citations on file: 2 on April 9, 2026, 16 on March 30, 2023, 3 on November 26, 2019.
Every fire safety citation21 citations
- E
Have restrictions on the use of highly flammable decorations.
K 753 · April 9, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 9, 2026 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 30, 2023 · 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 30, 2023 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have correct number of accessible exits for each story.
K 241 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 30, 2023 · Corrected (the home has a date of correction)
- E
Provide at least two remote exits on each floor or fire section of the building.
K 252 · March 30, 2023 · 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 30, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 30, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 26, 2019 · 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 · November 26, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 26, 2019 · Corrected (the home has a date of correction)