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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
1E
1F
Potential for minimal harm
0A
0B
0C
February 19, 2026Standard inspection · 1 citation
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on facility policy review, record review, review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely for 2 Residents (R)23 and R40 of 2 residents reviewed for resident assessment requirements.
January 30, 2025Standard inspection · 4 citations
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interviews and review of the facility's policy, it was determined the facility failed to ensure the individual assigned the responsibilities of the Infection Preventionist (IP) had received specialized training in infection control and prevention. This had the potential to affect all fifty (50) residents residing in the facility On 01/27/2025 at 7:05 PM, the entrance conference was conducted with the Administrator who revealed that the Staff Development Coordinator (SDC) was the designated Infection Preventionist (IP) for the facility.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview and review of facility policy, it was determined the facility failed to ensure that foods brought in by family and/or visitors were stored in a safe and sanitary manner for four of 13 sampled residents (Resident (R) 5, 6, 37, and R50) with personal in room refrigerators.
- 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 interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled residents (Resident (R) 12) receiving hemodialysis services. R12 began receiving off-site hemodialysis services on 12/26/2024; however, the facility failed to include the hemodialysis services on the resident's Comprehensive Care Plan.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained by the facility for one of four medication carts and one (1) of one (1) medication storage room. Observation during a narcotic count of the 100 Hall medication cart on 01/30/2025 at 11:00 AM with Licensed Practical Nurse (LPN) 2 revealed the narcotic count was incorrect for six narcotic medications belonging to four different residents (Resident (R) 4, 5, 10, and R16).
December 18, 2019Standard inspection · 3 citations
- 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 interview, record review, and facility policy review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of twelve (12) sampled residents (Resident #12). Resident #1 was care planned for one staff to provide oral care with dentures; however, observations revealed oral care was not being completed by staff.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to provide oral/denture care for one (1) of twelve (12 ) sampled residents, per facility policy (Resident #12).
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and review of the facility's policy, it was determined the facility failed to ensure the nurse staffing data was posted in a prominent place readily accessible to residents and visitors. Observations throughout the survey revealed the only staffing posted was dated 12/09/19, and included the staffing information for 12/09/19.
Fire safety inspections
17 fire safety citations on file: 10 on February 19, 2026, 5 on January 30, 2025, 2 on December 18, 2019.
Every fire safety citation17 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · February 19, 2026 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · February 19, 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 19, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 19, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 19, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 19, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 19, 2026 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · February 19, 2026 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 19, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 19, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 30, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · January 30, 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 30, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 30, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 30, 2025 · 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 · December 18, 2019 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · December 18, 2019 · Corrected (the home has a date of correction)