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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
1F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 4 citations
- F
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, and record review the facility failed to ensure injectable medications for two residents (R1 and R38) were labeled and dated when opened, and failed to ensure a multidose tuberculin vial was discarded after the expiration date when opened. These failures have the potential to affect all 55 residents residing in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and surgical wounds for six of six residents (R2, R8, R9, R18, R26, and R31) reviewed for EBP in the sample of 45.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who has a diagnosis of dementia was kept free from chemical restraints for one resident (R2) of six residents reviewed for antipsychotic medications in a sample of 45. Findings Include:The facility's Abuse policy dated 8/25/25 documents All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. This includes but is not limited to freedom from corporal punishment, and involuntary seclusion and physical or chemical restraints not required to treat the resident's symptoms. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to give medications as ordered by the physician for three of 15 residents (R22, R23 and R44) reviewed for medication pass in the sample of 45. This failure resulted in three errors out of twenty-six opportunities totaling an 11.5% medication error rate.
September 12, 2024Standard inspection · 0 citations
August 3, 2023Standard inspection · 1 citation
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview and record review the facility failed to document appropriate indications to warrant the use of an antipsychotic medication (R46) and attempt a gradual dose reduction (R19) for 2 of 5 residents reviewed for unnecessary medication in a sample of 23.
Fire safety inspections
13 fire safety citations on file: 4 on December 11, 2025, 2 on September 12, 2024, 7 on August 3, 2023.
Every fire safety citation13 citations
- 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 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 11, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 11, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · December 11, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 12, 2024 · 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 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 3, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 3, 2023 · 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 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper storage of liquid oxygen.
K 930 · August 3, 2023 · Corrected (the home has a date of correction)