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
1G
0H
0I
Potential for more than minimal harm
6D
0E
1F
Potential for minimal harm
0A
0B
1C
January 8, 2026Standard inspection · 3 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and document review, facility failed to ensure appropriate personal protective equipment (PPE) was properly utilized for 2 of 2 residents (R7 and R14) on enhanced barrier precautions (EBP), 1 of 1 resident (R58) on enhanced respiratory precautions (ERP). This had to potential to affect all residents the trained medication aide (TMA)-A came into contact with during her shift. In addition, facility failed to ensure infection control practices were followed when staff left used linens, towels and resident personal clothing on the floor for 2 of 2 residents (R7 and R14). The facility failed to ensure an attending clinical provider consistently wore a face mask while in patient areas during a period when the facility was in outbreak status, and masking interventions were being implemented facility wide. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide appropriate table height in the dining room for 1 of 2 residents (R33), reviewed for accommodation of needs.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure past recertification survey results were available for review. This had the potential to affect all 51 residents residing in the facility, as well as family, visitors and staff.
December 6, 2024Standard inspection, Complaint inspection · 5 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and document review, the facility failed to promptly obtain diuretic medication and failed to notify the physician to prevent the continued increase of carbon dioxide for 1 of 2 residents (R24) reviewed for medication errors. This practice resulted in a significant medication error and actual harm when R24 did not receive medication for 4 consecutive days resulting in R24 being sent to the emergency room to receive care for acute onset chronic respiratory failure with hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and hypercapnia (condition where there is too much carbon dioxide (CO2) in the blood).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and document review, the facility failed to ensure a level II preadmission screening and resident review (PASARR) was completed for 1 of 1 residents (R35) residents reviewed with a diagnosis of Mild intellectual Disability.
- 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 interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R35) reviewed for care planning.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to ensure proper wheelchair positioning and prevent potential complications for 2 of 2 residents (R6 and R19) reviewed for wheelchair usage.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of aspiration for 1 of 2 residents (R7) reviewed for nutrition and needing supervision at meals.
October 18, 2023Standard inspection · 1 citation
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 3 of 3 residents (R36, R19, R39) were comprehensively assessed for safety and ability to self-administer medications who were reviewed for medication administration.
Fire safety inspections
7 fire safety citations on file: 4 on January 8, 2026, 1 on December 6, 2024, 2 on October 18, 2023.
Every fire safety citation7 citations
- E
Have exits that are accessible at all times.
K 271 · January 8, 2026 · deficient, provider has
- 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 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 6, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 18, 2023 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · October 18, 2023 · Corrected (the home has a date of correction)