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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
0B
0C
February 26, 2026Standard inspection · 4 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for three Residents (Resident #48 and Resident # 4) out of 20 sampled residents. As evidenced by facility staff observed standing while feeding Resident #48 and observation of Resident #4's indwelling urinary catheter drainage bag without a privacy cover. There were 69 residents residing in the facility at the time of the survey.
- 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 observations, record review and interviews, the facility failed to provide safe and secure storage of biologicals for two Residents (#20 and #83) out of 20 residents sampled. There were 69 residents residing in the facility at the time of the survey.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to demonstrate that effective action plans were implemented and sustained to correct identified quality deficiencies related to repeated deficient practice for F761 Label/Store Drugs and Biologicals. There were 69 residents residing in the facility at the time of the survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for the environment and three Residents (Resident #17, Resident #20 and Resident, #83). As evidenced by Two Urinals, one Spirometer, and one Adult Brief were not stored in compliance with infection control standards. There were 69 residents residing in the facility at the time of the survey.
February 19, 2025Standard inspection · 2 citations
- 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 record review the facility failed to follow pharmaceutical procedures as per facility policy. As evidenced by during observations of one of two Medication storage rooms reviewed, the narcotics lock box in the medication refrigerator was noted unlocked. and Resident #180's medication was being given in tablet form and the order documented capsule. There were 74 residents residing at the facility at the time of the survey.
- 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 observations interviews and record review, the facility failed to provide appropriate storage of medications on the medication cart for one (1) of three (3) medication carts observed. As evidenced by during observation of one out of three (3) medication carts loose pills were noted in different compartments of the medication drawer and in one out of two medication rooms Narcotics Lock Box was left unlocked. There were 74 residents residing at the facility at the time of the survey.
January 8, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews, the facility failed to ensure one (Resident #2) out of three sampled residents received care and treatment in accordance with professional standards of practice related to the timely reporting of a fall to the resident's physician resulting in a delay in care for a fracture. X-rays at the hospital revealed Resident # 2 incurred an acute fracture involving the right superior and inferior pubic rami. There were 69 residents residing in the facility at the time of the survey.
November 30, 2023Standard inspection · 2 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Residents complained the call lights were left unanswered for over 15 minutes in multiple occasions when they called for assistance. There were 68 residents residing in the facility at the time of the survey.
- D
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 observations, record review and interviews, the facility failed to respond to grievances for one out of one resident (Resident #44) reviewed for grievances. The resident's family member (Brother) established communication with the facility concerning complaints regarding the resident's loss of items, but no grievance was filed. There were 68 residents residing in the facility at the time of the survey.
Fire safety inspections
2 fire safety citations on file: 1 on February 26, 2026, 1 on February 19, 2025.
Every fire safety citation2 citations
- E
Have proper medical gas storage and administration areas.
K 923 · February 26, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 19, 2025 · Corrected (the home has a date of correction)