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 4 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
0F
Potential for minimal harm
0A
0B
0C
February 4, 2026Standard inspection · 0 citations
December 4, 2024Standard inspection · 0 citations
December 12, 2023Standard inspection · 4 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 observations, interviews, policy review, and record review for one Resident (#239), of 12 sampled residents, the facility failed to ensure his/her comprehensive and individualized plan of care was implemented. Specifically, the facility failed to follow his/her care plan and maintain aspiration precautions as indicated.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an extra dose of an antibiotic was not administered to one Resident (#16), out of a total sample of 12 residents. Specifically, the facility failed to monitor the date and the time the Resident should have received the last dose.
- 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, document review, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure medications and vaccines were stored at proper temperatures to preserve their integrity in one of two medication refrigerators reviewed.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on record review, document review, Nursing Facility Service Agreement, and interview, the facility failed to ensure Hospice provided information and documentation regarding care and services as required in the provider contract agreement, including a designated facility coordinator for one Resident (#18), out of a total sample of 12 residents. Specifically, the facility failed to ensure the hospice service provider completed hospice information in the Resident's record, which included initial certification, the most current Hospice Plan of Care, and the Physician Recertification of Terminal Illness in order to assure coordination and collaboration of care.
Fire safety inspections
21 fire safety citations on file: 3 on February 4, 2026, 6 on December 4, 2024, 12 on December 12, 2023.
Every fire safety citation21 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 4, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 4, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 4, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 4, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 4, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 4, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 4, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · December 4, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 4, 2024 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · December 12, 2023 · Past noncompliance: already fixed when inspectors found it
- F
Establish policies and procedures for sheltering.
E 22 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · December 12, 2023 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · December 12, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 12, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 12, 2023 · Corrected (the home has a date of correction)