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
0G
0H
0I
Potential for more than minimal harm
6D
3E
0F
Potential for minimal harm
0A
0B
0C
March 6, 2026Standard inspection · 6 citations
- E
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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for three of four medication carts reviewed (North two, South, and [NAME] medication carts).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for two of six residents reviewed (Residents R23 and R51).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of five residents reviewed (Residents R67 and R71).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate treatment to prevent potential complications related to a gastrostomy tube (g-tube - a tube inserted through a small incision in the abdomen into the stomach, used for the administration of liquid nutrition and medications) for one of three residents reviewed (Resident R64).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician's orders for two of three residents reviewed for respiratory care (Residents R18 and R23).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination (transfer of germs from one location to another) during medication administration (West Wing medication cart) and failed to prevent cross-contamination for one resident (Resident R122) receiving nebulizer treatments ( a treatment that delivers medication directly to the lungs to treat respiratory conditions).
January 23, 2026Complaint 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 review of clinical records, facility policy, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding personal hygiene, oral hygiene, toileting, and dressing for three of three residents reviewed (Residents R1, R2, and R3).
June 13, 2025Complaint inspection · 1 citation
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of four nursing units (West Hall Nursing Unit).
March 19, 2025Standard 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 review of facility policy and manufacturer's instructions, observations and staff interview, it was determined that the facility failed to label one multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD-testing solution for tuberculosis) injection with the date it was opened and date it should be used by in one of three medication storage rooms observed (North Two Nurse Station medication room).
April 11, 2024Standard inspection · 0 citations
Fire safety inspections
20 fire safety citations on file: 5 on March 6, 2026, 10 on March 19, 2025, 5 on April 11, 2024.
Every fire safety citation20 citations
- E
Install a two-hour-resistant firewall separation.
K 133 · March 6, 2026 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 6, 2026 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · March 6, 2026 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · March 6, 2026 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 6, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 19, 2025 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · March 19, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 19, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 19, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 19, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 19, 2025 · Corrected (the home has a date of correction)
- C
Have properly located and lighted "Exit" signs.
K 293 · March 19, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 19, 2025 · Corrected (the home has a date of correction)
- C
Have power receptacles that are properly grounded.
K 912 · March 19, 2025 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · March 19, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 11, 2024 · Corrected (the home has a date of correction)
- D
Have power receptacles that are properly grounded.
K 912 · April 11, 2024 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · April 11, 2024 · Corrected (the home has a date of correction)