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 12 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
4E
0F
Potential for minimal harm
0A
0B
0C
February 13, 2026Complaint inspection · 2 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure the proper repositioning of a dependent resident was performed for 1 (#3) of 3 sampled residents reviewed for safe transfers. The regional nurse consultant identified 65 residents resided in the facility.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was assessed for pain while being repositioned in bed for 1 (#3) of 4 sampled residents reviewed for pain. The regional nurse consultant identified 65 residents resided in the facility.
August 26, 2025Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure responsible parties were notified of a change in condition for 1 (#1) of 3 sampled residents reviewed for notifying responsible parties of a change in condition. The administrator identified 68 resided in the facility.
- 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, record review, and interview, the facility failed to ensure medications were administered according to physicians' orders for 1 (#2) of 6 residents sampled for medications administered according to physician orders. The administrator identified 68 resident received medication from the facility.
January 16, 2025Standard inspection, Complaint inspection · 7 citations
- E
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 refer a resident with newly diagnosed mental illness diagnoses to the OHCA for a level II PASARR evaluation for one (#40) of two sampled residents reviewed for PASARR. The administrator reported 67 residents resided in the facility.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to transcribe a physician order and schedule a mammography in a timely manner as requested for one (#41) of one resident reviewed for a physician ordered mammography. The administrator reported 67 residents resided in the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to follow their policy to ensure a safe environment for smokers for two (#45 and #55) of two residents sampled for accident hazards. The administrator reported 10 residents who smoked, seven of which were unsupervised smokers.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper disposal of blood contaminated glucometer strips for one (#52) of two sampled residents reviewed for finger stick blood sugar levels. The DON reported 25 residents received finger stick blood sugar levels.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to treat a resident with dignity and respect while providing assistance with eating for one (#33) of one resident sampled for resident rights. The administrator reported 67 residents resided in the facility. A Telephones, Employees Use of policy, dated July 2010, read in part, cellular phones may be used for personal calls and text messaging ONLY when the employee was on authorized meal and break periods. Employee cell phones will remain off and/or silent during all other work hours. Failure to comply with cellular phone policies may result in disciplinary action. Resident #33 had diagnoses which included Alzheimer's disease, depression, and seizure disorder. An MDS assessment for Resident #33, dated 11/18/24, documented the resident had severely impaired decision making. [...]
- 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 observation, record review, and interview, the facility failed to maintain a comfortable room temperature for one (#16) of four residents sampled for the environment. The administrator reported 67 residents resided in the facility.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to complete a MDS discharge assessment when the resident was discharged from the facility for one (#63) of one sampled resident reviewed for comprehensive assessments. The administrator reported 67 residents resided in the facility.
April 30, 2024Complaint inspection · 1 citation
- 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 and interview, the facility failed to ensure medications were stored properly and according to facility policy. The Administrator reported 66 residents resided in the facility.
October 26, 2023Standard inspection · 0 citations
May 26, 2022Standard inspection · 0 citations
Fire safety inspections
16 fire safety citations on file: 2 on January 16, 2025, 3 on October 26, 2023, 11 on May 26, 2022.
Every fire safety citation16 citations
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 16, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 16, 2025 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · October 26, 2023 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · October 26, 2023 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · May 26, 2022 · deficient, provider has
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 26, 2022 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 26, 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 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 26, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 26, 2022 · Corrected (the home has a date of correction)