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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
1E
1F
Potential for minimal harm
0A
0B
2C
March 27, 2026Complaint inspection · 3 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dependent resident received assistance eating for 1 of 3 residents reviewed for assistance with activities of daily living (ADL). (Resident B)
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dependent resident prescribed with a mechanically altered diet received ground meat for the breakfast meal for 1 of 3 residents reviewed for meal service. (Resident B)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's meal consumption had been documented accurately for 1 of 3 residents reviewed for documentation. (Resident B)
February 23, 2026Standard inspection · 4 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical information was kept confidential and located in a secure location for 13 of 93 residents who reside in the facility reviewed for confidentiality of records. (Residents 9, Resident 58, Resident 62, Resident 74, Resident 76, Resident 86, Resident 96, Resident 101, Resident 103, Resident 104, Resident 105, Resident 115, Resident 116)
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed for medications left at bedside of 1 of 32 resident rooms. (Resident 79)
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were revised to reflect accurate code status for 2 of 22 residents reviewed for care plan accuracy. (Resident 12 and Resident 60)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precaution infection control practices for 1 of 4 residents reviewed for wounds. (Resident 45).
April 28, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to a resident that resided on the secured memory unit and had a history of exit seeking behaviors, from exiting the facility through a window in his room. The day of the elopement the resident was angry, exit seeking, trying to leave, stated he needed out of there. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/15/25 at approximately 6:20 p.m., when the facility failed to provide supervision to a cognitively impaired resident, that resided on the memory care unit, to prevent an elopement. The Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Director of Nursing were notified of the Immediate Jeopardy on 4/24/25 at 2:00 p.m. [...]
March 6, 2025Complaint inspection · 1 citation
- 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, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 1 kitchen observations and 1 of 1 pantry observations. Dry food storage room and kitchen were not thoroughly cleaned and food was not labeled and dated.
January 22, 2025Standard inspection · 2 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was referred to the State-designated authority contractor for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a new mental illness diagnosis for 1 of 1 resident reviewed for PASRR. (Resident 65)
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the area next to the trash dumpster container was free from rubbish for 2 of 2 observations.
February 26, 2024Standard 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, interview, and record review, the facility failed to ensure medications were stored in accordance with accepted principles for 1 of 3 medication carts reviewed and two random observations of treatment carts. Medication and treatment carts were unlocked and insulin did not have an open date. (300 Hall Medication Cart, 300 Hall Treatment Cart)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted nurse staffing document reflected the actual hours worked for 3 of 3 observations.
Fire safety inspections
13 fire safety citations on file: 5 on February 23, 2026, 5 on January 22, 2025, 3 on February 26, 2024.
Every fire safety citation13 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 23, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 23, 2026 · 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 · February 23, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 23, 2026 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 23, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 22, 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 · January 22, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 22, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 22, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 26, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · February 26, 2024 · 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 · February 26, 2024 · Corrected (the home has a date of correction)