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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
1E
0F
Potential for minimal harm
0A
1B
0C
December 17, 2025Standard inspection, Complaint inspection · 3 citations
- J
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 interviews with staff, Nurse Practitioner and Physician, the facility failed to provide the necessary supervision to prevent an avoidable accident for a resident who had severe cognitive impairment, was on a pureed diet, had a diagnosis of dysphagia (difficulty swallowing), and required staff assistance with eating due to his inability to control the speed and/or quantity of food that entered his mouth (Resident #132). On Saturday, 10/11/25 around 8:30 AM, Nurse Aide #8 left a meal tray in front of Resident #132 so she could pass the remaining meal trays. Shortly after meal trays were passed, Nurse Aide #1 found Resident #132 unresponsive and not breathing. Nurse Aide #1 called for help and code blue (life threatening medical emergency) was called. [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review, and staff and Pharmacist interviews, the facility failed to have a copy of a monthly medication regimen review (MRR) available for review for 1 of 5 residents reviewed for unnecessary medications (Resident #4).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #4 and NA #5 failed to apply personal protective equipment (PPE) during urinary catheter care for a resident on Enhanced Barrier Precautions (EBP). This deficient practice was for 2 of 2 staff members observed for infection control practices (NA #4 and NA #5).
September 6, 2024Standard inspection · 1 citation
- 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, resident, facility staff, pharmacist, and Nurse Practitioner (NP) interviews the facility failed to obtain a narcotic refill prescription to provide pain medication for 1 of 3 residents reviewed for pain management (Resident #57).
February 15, 2024Complaint inspection · 1 citation
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately document on the electronic Medication Administration Record (eMAR) when cardiac medications were withheld according to parameters defined by the physician's orders for 3 of 3 residents reviewed for medication administration (Resident's #1, #2, and #3). 1. Resident #1 was admitted to the facility on [DATE] and discharged on 01/10/24 with diagnosis that included atrial fibrillation, nonrheumatic mitral valve insufficiency, atherosclerotic heart disease of the coronary artery, the presence of an automatic implantable cardiac defibrillator, and stroke. Review of the physician orders for Resident #1 revealed the following order : [...]
November 15, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and staff interviews the facility failed to follow physician orders regarding placement of Lidocaine external patch, a local anesthetic, for 1 of 5 residents (Resident #1) reviewed for physician order implementation.
April 26, 2023Standard inspection · 3 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, record review and staff interview the facility failed to monitor temperatures for 1 of 1 medication refrigerators (300 Hall medication room refrigerator) and failed to discard expired medication for 2 of 3 medications carts (400 Hall medication cart, 500 Hall medication cart).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review, observation, and staff interview, the facility ' s Quality Assurance and Assessment (QAA) Committee failed to maintain implemented procedures and monitor interventions put in place following the recertification and complaint investigation survey of [DATE]. This was for a deficiency in the area of Label/Store Drugs and Biologicals (F761) originally cited on [DATE], recited on a recertification follow up survey on [DATE], and subsequently recited on the current recertification survey of [DATE]. The continued failure of the facility during three federal surveys of record shows a pattern of the facility ' s inability to sustain an effective Quality Assurance program.
- B
Post nurse staffing information every day.
Inspectors wroteBased on observations record review and staff interviews, the facility failed to post the accurate census on the daily nurse staffing sheets for 2 of 4 days (4/23/23 and 4/24/23) of the recertification survey.
Fire safety inspections
10 fire safety citations on file: 7 on September 6, 2024, 2 on April 26, 2023, 1 on December 16, 2021.
Every fire safety citation10 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 6, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 6, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 6, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 6, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 26, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 26, 2023 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 16, 2021 · Corrected (the home has a date of correction)