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
1G
0H
0I
Potential for more than minimal harm
11D
1E
0F
Potential for minimal harm
0A
0B
0C
March 26, 2026Complaint inspection · 1 citation
- 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 resident representative and staff interview, medical record review, and policy and procedure review, the facility failed to ensure a notification of change of condition was given for 1 of 3 sample residents (#6) reviewed for a change in condition.
November 18, 2025Standard inspection, Complaint inspection · 4 citations
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, medical record review, and staff and resident interview, the facility failed to promote and facilitate resident choice and preferences for 1 of 2 sample residents (#12) reviewed.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure a Level II PASRR (preadmission screening and resident review) evaluation was completed prior to admission for 1 of 1 residents (#123) reviewed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, policy and procedure review, medical record review, and resident and staff interview, the facility failed to ensure effective pain management was provided to 1 of 4 residents (#12) reviewed for pain management.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and review of policy and procedures and standards of practice, the facility failed to ensure effective infection prevention practices were implemented during one random observation of linen transportation. The census was 119.
September 5, 2024Complaint 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 observation, staff interview, and policy and procedure review, the facility failed to ensure medications were safely stored during 1 of 2 observations of medication administration. The census was 113.
June 6, 2024Standard inspection, Complaint inspection · 2 citations
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised as needed to reflect the resident's current needs for 1 of 23 sample residents (#5).
- 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 medical record review, staff interview, and policy and procedure review, the facility failed to ensure medication-specific target symptoms were identified and monitored for 2 of 5 sample residents (#5, #29) reviewed for unnecessary medication use.
March 2, 2023Standard inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, resident representative and staff interview, and review of policy and procedure, the facility failed to ensure adequate interventions were in place to prevent accidents for 1 of 4 sample residents (#199) reviewed for accidents. This failure resulted in harm to resident #199, who sustained fractures after a fall.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, staff interview, and policy and procedure review, the facility failed to ensure 1 of 2 medical record storage areas (Therapy West) were safeguarded from unauthorized use.
- 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 observation, medical record review, resident and staff interview, and review of facility policy and procedure, the facility failed to ensure 2 of 26 sample residents (#19, #28) had resident-specific care plans that reflected individual needs in all required areas.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physician's orders for 1 of 26 sample residents (#73) reviewed.
- 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 observation, staff interview, policy and procedure review, and professional standard review the facility failed to ensure medications were labeled in accordance with professional standards in 1 of 4 medication storage units (Therapy South medication cart).
Fire safety inspections
22 fire safety citations on file: 15 on November 18, 2025, 2 on June 6, 2024, 5 on March 2, 2023.
Every fire safety citation22 citations
- F
Provide emergency officials' contact information.
E 31 · November 18, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · November 18, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 18, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 18, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 18, 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 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 18, 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 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · November 18, 2025 · Corrected (the home has a date of correction)
- 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 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 18, 2025 · Corrected (the home has a date of correction)
- E
Meet Health Care Facilities Code mechanical requirements.
K 900 · June 6, 2024 · Waiver
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 2, 2023 · Corrected (the home has a date of correction)
- E
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 2, 2023 · Corrected (the home has a date of correction)
- 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 · March 2, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · March 2, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 2, 2023 · Corrected (the home has a date of correction)