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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
8E
0F
Potential for minimal harm
0A
0B
0C
February 11, 2026Standard inspection · 4 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 observations, record review and interview, the facility failed to ensure it stored all drugs and biologicals in locked compartments by having medications stored in resident rooms for 2 (#26, #72) of 2 sampled residents observed for medication storage.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record reviews and interviews, the facility failed to address the resident right to be informed of his or her treatment in advance, by the physician or other practitioner or professional, of the risks and benefits of psychotropic medication treatment. The facility failed to ensure consent for psychotropic medication was obtained for 2 (#7, #60) of 5 residents reviewed for unnecessary medications.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (#23, #60) of 5 residents reviewed for falls. The facility failed to ensure:1. Proper functioning of Resident #23's motion sensor, and2. A wheelchair brake extender was on Resident #60's wheelchair as stated in the care plan.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Facility staff failed to utilize gown and gloves during high contact resident care activities for 2 (#7, #15) of 2 residents observed.
December 11, 2024Standard inspection · 4 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#276) of 1 (#276) resident reviewed for restraints.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the assessments accurately reflected the residents' status by failing: 1) to ensure assessments were completed in a timely manner for 1 (#35) of 5 (#13, #16, #35, #48, #276) reviewed for unnecessary medications, 2) to accurately assess the resident's skin during weekly skin/body assessments for 1 (#33) of 3 (#33, #11, #40) residents reviewed for pressure ulcers, 3) to accurately assess a resident's dental status for 1 (#9) of 1 (#9) resident reviewed for dental issues, and 4) to ensure accurate daily nursing assessments were completed for 1 (#53) of 2 (#53, #303) residents reviewed for urinary catheter or urinary tract infections (UTI).
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to monitor for bleeding risks for 1 (#16) of 5 (#13, #16, #35, #48, #276) residents reviewed for unnecessary medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff followed infection control prevention standards by failing to wear a gown for 1 (#33) of 2 (#33, #11) residents observed for Enhanced Barrier Precaution (EBP) isolation during wound care.
October 25, 2023Standard inspection · 5 citations
- E
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 record reviews and interviews the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (#10, #282) of 4 (#10, #61, #282, and #283) residents reviewed for urinary tract infections. The facility failed to ensure resident #10 and #282 received antibiotics to treat a urinary tract infection as ordered by the physician.
- E
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 interview, the pharmacy consultant failed to identify and report irregularities to the physician and director of nursing for 1 (#51) of 5 (#14, #40, #49, #51, #75) residents reviewed for unnecessary medications. The pharmacist consultant failed to identify the facility had not obtained an annual lipid level for Resident #51.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the provider failed to ensure each resident's medication regimen was free from unnecessary medications by failing to obtain an annual lipid panel for 1 (#51) of 5 (#14, #40, #49, #51, #75) residents whose medication regimens were reviewed.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. 1) The facility failed to ensure all glucose testing items were disinfected prior to storing inside of the medication cart; 2) The facility failed to ensure employee personal items were not stored in the designated clean laundry room; and, 3) The facility failed to ensure the laundry department was free of dust and lint build-up.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent avoidable accident hazards for 1 of (#46) of 4 (#40, #46, #50, and #68) residents sampled for falls.
Fire safety inspections
3 fire safety citations on file: 1 on December 11, 2024, 1 on October 25, 2023, 1 on September 21, 2022.
Every fire safety citation3 citations
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 11, 2024 · deficient, provider has
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 25, 2023 · Waiver
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 21, 2022 · Waiver