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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
1E
0F
Potential for minimal harm
0A
0B
1C
March 19, 2026Standard inspection · 6 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure water temperatures were appropriate. This affected one (Resident #25) of three reviewed for environmental concerns and had the potential to affect all 54 residents in the facility.
- 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 and interview, the facility failed to ensure care plans were comprehensive. This affected three Residents (Residents #2, #11 and #50) of 18 reviewed for care plans and had the potential to affect all 54 residents in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to provide transportation to medical appointments as needed for Resident #11. This affected one resident (#11) of one resident who was investigated for transportation needs. The facility census was 54.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure pressure reducing interventions were in place as ordered by the physician for Resident #50. This affected one resident (#50) of three residents reviewed for pressure ulcers and had the potential to affect five additional residents (#4, #5, #16, #62 and #64) identified by the facility with pressure ulcers. The facility census was 54.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure that Resident #7's therapy recommendation for built up utensils at all meals was properly assessed, that a corresponding physician's order was obtained, and that the intervention was incorporated into the care plan. This affected one resident (#7) of one resident reviewed for assistive devices and had the potential to affect three additional residents (#16, #20, and #48) identified by the facility as utilizing assistive devices. The facility census was 54.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, interview and review of facility policies, the facility failed to provide wound care to Resident #16 in a manner to prevent infection. This affected one resident (#16) of two residents observed for wound care. The facility census was 54.
February 25, 2025Standard inspection · 2 citations
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of the facility Self-Reported Incident (SRI) and related facility investigation, and policy review, the facility did not ensure Residents #2, #4, #23, and #35 were free from the misappropriation of their controlled substance narcotic pain medication. This affected four residents (Resident #2, #4, #23, and #35) out of four residents reviewed for misappropriation of property. This had the potential to affect 14 residents (#1, #2, #4, #8, #11, #21, #23, #26, #32, #33, #35, #36, #39, and #153) the facility identified as residing on the A unit and had orders for controlled substances. The facility census was 48.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, review of QSO-24-08-NH memorandum, and review of facility policy revealed the facility did not utilize enhance barrier precautions (EBP) when indicated for Residents #17 during the administration of medication through his percutaneous endoscopic gastrostomy (PEG) tube. This affected one Resident (#17) out of two residents observed for EBP. The facility identified 11 Residents (#3, #4, #11, #17, #22, #28, #36, #42, #38, #39, #153) who required EBP. The facility census was 48.
January 4, 2024Complaint inspection · 2 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview, record review and policy review, the facility failed to implement the abuse policy and procedure after receipt of an allegation of staff to resident verbal abuse for Resident #53. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review and policy review, the facility failed to report an allegation of staff-to-resident verbal abuse for Resident #53 to the state agency. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52.
November 15, 2022Standard inspection · 3 citations
- 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 observation, interview, and record review, the facility failed to ensure Resident #25 had bilateral hand splints as ordered. This affected one resident (Resident #25) out of one resident reviewed for splints.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure the pharmacy delivered medications in a timely manner to ensure Resident #44 and Resident #99 received intravenous antibiotics as scheduled. This affected two residents (Resident #44 and Resident #99) out of five residents reviewed for medication administration.
- C
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 51 residents in the facility.
Fire safety inspections
11 fire safety citations on file: 1 on March 19, 2026, 4 on February 25, 2025, 6 on November 15, 2022.
Every fire safety citation11 citations
- E
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 · March 19, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 15, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · November 15, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · November 15, 2022 · 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 15, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 15, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 15, 2022 · Corrected (the home has a date of correction)