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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
14D
3E
0F
Potential for minimal harm
0A
0B
0C
July 7, 2026Complaint inspection · 6 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review, staff and resident representative interview, the facility failed to ensure an assessment was performed for 7 of 9 sample residents (#1,#3, #4, #5, #6, #7, #8) reviewed for change of condition. This failure resulted in actual harm to residents #4 and #8 who experienced a delay in treatment.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on resident interview, resident representative interview, staff interview, record review and policy review, the facility failed to properly obtain grievances and maintain evidence demonstrating the appropriate action and issuance of the grievance decision without repercussions for 4 of 4 residents (#1, #2, #3, #17) reviewed for grievances.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure written bed hold and transfer notices were given to 6 of 7 (#2, #3, #4, #5, #6, #7) residents reviewed for transfers.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on resident representative interview, staff interview and record review, the facility failed to ensure that residents received necessary respiratory care for 1 of 3 (#1) residents reviewed for respiratory care.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, and resident representative and staff interview, the facility failed to ensure a pharmaceutical services procedure related to accurate acquiring, receiving, dispensing and administration of medications for 1 of 4 sample residents (#1) reviewed for medication availability.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident representative and staff interview, medical record review, and manufacturer's recommendation review, the facility failed to ensure residents were free from significant medication error for 1 of 4 (#1) residents reviewed for medication administration.
April 30, 2026Complaint inspection · 2 citations
- 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, medical record, and staff and resident interview, the facility failed to ensure medications were safely stored for 1 of 3 residents (#1) reviewed for medication administration. The census was 64.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and policy and procedure review, the facility failed to ensure infection control techniques were utilized in 1 of 4 units.
April 2, 2026Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff and resident representative interview, medical record review, facility investigation review, Office of Healthcare Licensing and Surveys ([NAME]) incident report log review, and policy and procedure review, the facility failed to report an injury of unknown source within 2 hours to the State Agency for 1 of 3 sample residents (#1) reviewed for allegations of abuse. The census was 64.
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on medical record review, staff interview, and provider interview, the facility failed to ensure a safe and orderly discharge from the facility for 1 of 3 sample residents (#2) reviewed for discharge.
February 26, 2026Complaint inspection · 2 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure residents received adequate supervision and devices to prevent accidents for 5 of 5 sample residents (#1, #9, #10, #11, #15) reviewed for accident hazards. This failure resulted in actual harm to resident #1 who received burns from hot liquid. The failure resulted in a determination of immediate jeopardy due to a lack of implementation of interventions, including adequate supervision and use of safety equipment. The census was 67.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 7 sample residents (#2) reviewed for abuse. This failure resulted in actual harm to resident #2. The facility had implemented corrective action prior to the survey and was found to be in substantial compliance as of 9/11/25.
March 6, 2025Standard inspection, Complaint inspection · 4 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, resident and staff interview, facility incident investigation review, state survey agency incident database review, and policy review, the facility failed to report allegations of misappropriation of resident property for 1 of 3 sample residents (#59) reviewed for abuse, neglect, and misappropriation.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, medical record review, staff interview, facility activities calendar review and policy and procedure review, the facility failed to provide an activities program designed to support residents in their choice of activities for 1 of 2 sample residents (#48) with activity concerns.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, medical record review, and staff and resident interview, the facility failed to ensure resident diet orders were followed for 1 of 3 sample residents (#50) reviewed for food and nutrition.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, staff interview, professional standard review, and policy review, the facility failed to ensure infection prevention practices were implemented for 1 of 2 sample residents (#2) observed during personal care.
October 24, 2024Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 9 sample residents reviewed. This failure resulted in actual harm to resident #1.
December 21, 2023Standard inspection, Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, resident and staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sample residents (#65) reviewed for abuse. The facility implemented corrective actions and was determined to be in substantial compliance as of 11/22/23.
October 27, 2022Standard inspection · 3 citations
- 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, staff interview, review of facility policy, and review of the 2017 U.S. Public Health Service food code, the facility failed to ensure sanitary meal service during 1 of 2 meal observations (evening meal on 10/24/22). The facility census was 64.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure appropriate safety devices were utilized during transfers for 1 of 3 sample residents (#9) reviewed for falls.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, staff interview and policy review the facility failed to ensure appropriate infection prevention practices during 1 of 2 observations of wound dressing changes (which affected resident #166).
Fire safety inspections
11 fire safety citations on file: 4 on March 6, 2025, 2 on December 21, 2023, 5 on October 27, 2022.
Every fire safety citation11 citations
- F
Include a process for Emergency Preparedness collaboration.
E 9 · March 6, 2025 · 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 6, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 6, 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 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 21, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · December 21, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 27, 2022 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · October 27, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 27, 2022 · 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 · October 27, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 27, 2022 · Corrected (the home has a date of correction)