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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
3E
0F
Potential for minimal harm
0A
0B
0C
February 10, 2026Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on policy review, Administrator job description review, Director of Nursing (DON) job description review, National Weather Service website review, medical record review, facility video footage review, facility investigation review, hospital record review, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #1) sampled residents assessed to be at risk for wandering and exit seeking behaviors. Immediate Jeopardy was identified when Resident #1 a vulnerable and cognitively impaired resident with a history of wandering behaviors, exited the building without staff knowledge or assistance on 1/31/2026. [...]
October 14, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 1 staff (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) during peg tube (a tube inserted into the stomach for the administration of medications or nutrients) care for 1 of 3 (Resident #9) sampled residents reviewed for peg tubes, and when 2 of 2 staff (LPN B and Certified Nursing Assistant (CNA) C) failed to perform hand hygiene during wound and urinary catheter (a tube placed in the bladder to drain urine) care for 2 of 2 (Residents #10 and #13) sampled residents reviewed.
August 11, 2022Standard inspection · 6 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure investigations, neurological (neuro) checks, and assessments were completed for 3 of 3 sampled residents (Resident #55, #70, and #149) reviewed for falls and accident hazards.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 3 of 5 sampled residents (Resident #5, #55, and #110) reviewed for unnecessary medications failed to receive antihypertensives (medication to lower blood pressure), cardiac (heart), and renal (kidney) medications, Insulin (medication to lower blood sugar), anticoagulants (medication to thin the blood), and anticonvulsants (treats seizures) as ordered and when 1 of 7 nurses (Licensed Practical Nurse (LPN) #2) failed to administer an antihypertensive medication as ordered for 1 of 10 sampled residents (Resident #37) observed during medication administration.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide education for Advance Directives to residents or residents' responsible parties for 4 of 32 sampled residents (Resident #98, #101, #154, and #565) reviewed for Advanced Directives.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide 1 of 3 sampled residents (Resident #82) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued, and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on the policy review, medical record review, observation, and interview, the facility failed to follow the facility's policy for a Midline Catheter (a long catheter that is placed through the skin into a vein) dressing for 1 of 2 sampled residents (Resident #267) reviewed for a Midline Catheter.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were followed when 1 of 1 nurses (Treatment Nurse) failed to perform proper hand hygiene and cleaned 2 separate wound areas with the same gauze pad during wound care for 2 of 2 sampled residents (Resident #55 and #114) reviewed during wound care.
October 22, 2019Standard inspection · 3 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 medical record review and interview, the facility failed to immediately notify the physician of hypoglycemia (low blood glucose level results) for 1 of 3 (Resident #36) sampled residents reviewed for significant change in condition.
- 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 policy review, observation, and interview the facility failed to ensure medications were stored properly when expired medications were found in 1 of 11(First Floor Medication Room) medication storage areas.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly disinfect a glucometer (glucose testing machine) after use and when 1 of 1 (Respiratory Therapist (RT) #1) staff failed to perform proper hand hygiene during tracheostomy care.
December 6, 2018Standard inspection · 5 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 6 of 8 (Licensed Practical Nurse (LPN) #1, 2, 3, and 4, Certified Nursing Assistant (CNA) #1, and Respiratory Therapist (RT) #1) staff members failed to perform appropriate infection control practices during medication administration, catheter care, wound care, and tracheostomy care observations and when an indwelling urinary catheter bag was on the floor for 1 of 6 (Resident #111) sampled residents reviewed with an indwelling urinary catheter.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when an indwelling urinary catheter bag was not in a dignity bag for 1 of 6 (Resident #111) sampled residents reviewed with an indwelling urinary catheter.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview, the facility failed to accurately assess residents for nutrition and hospice for 3 of 32 (Resident #36, 96, and 136) sampled residents reviewed.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 2 of 6 (Resident #3 and 42) sampled residents reviewed for indwelling urinary catheters.
- 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 policy review, observation, and interview, the facility failed to ensure medications were securely and properly stored when 1 of 5 (Licensed Practical Nurse (LPN) #1) nurses left a medication cart unlocked and insulin was not dated when opened in 1 of 6 (100 Hall Cart 2 medication cart) medication storage areas.
Fire safety inspections
19 fire safety citations on file: 4 on August 11, 2022, 13 on October 22, 2019, 2 on December 6, 2018.
Every fire safety citation19 citations
- D
Install an approved automatic sprinkler system.
K 351 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 11, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Establish an Emergency Preparedness Program (EP).
E 1 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · October 22, 2019 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 6, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 6, 2018 · Corrected (the home has a date of correction)