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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
0E
1F
Potential for minimal harm
0A
0B
2C
July 16, 2026Standard inspection · 2 citations
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure their medication error rate was less than five percent (%). There were two medication errors out of 27 opportunities resulting in a 7.41% medication error rate. This affected two (Residents #11 and #37) of eight residents observed for medication administration. The facility census was 40.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policy, the facility failed to ensure infection control practices were maintained for two residents who required Enhanced Barrier Precautions (EBP) during high contact resident care activities. This affected two (Residents #31 and #48) of two residents observed for EBP. The facility identified there were a total of seven current residents who had EBP in place. The facility census was 40.
November 24, 2025Complaint inspection · 1 citation
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on medical record review, review of facility policy, review of facility education in-service, review of a disciplinary action form, and staff interview, the facility failed to ensure care and services for a peripherally inserted central catheter (PICC) line site were completed as ordered. This affected one resident (#70) of three residents reviewed for intravenous (IV) access. The facility census was 66.
August 24, 2023Standard inspection · 6 citations
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure Resident #64 was free from physical restraints. This affected one resident (#64) of one resident reviewed for restraints. The facility census was 104.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, interview, review of the fall investigations, and facility policy review the facility failed to ensure fall prevention interventions were in place to prevent falls for Resident #78 and failed to ensure falls were thoroughly investigated. This affected one resident (#78) of three residents reviewed for accidents. The facility census was 104.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure a prescribed antibiotic was not given for more than 14 days without a rationale. This affected one resident (#15) of five residents reviewed for unnecessary medications. The facility census was 104.
- 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 record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were utilized, failed to ensure anti-anxiety medications were used for the intended purpose and not used for longer than 14 days without a rationale. This affected three residents (#48, #71, and #94) of five residents reviewed for unnecessary medications. The facility census was 104.
- C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and staff interview the facility failed to ensure its facility assessment contained necessary required information. This had the potential to affect all 104 residents residing in the facility.
- C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 104.
January 16, 2020Standard inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview the facility failed to develop a comprehensive infection control program to decrease the risk of infections and ensure adequate monitoring of infections was completed. The facility failed to maintain consistent use of isolation precautions for Resident #9 and failed to ensure dressing changes were completed to reduce the risk of infection for Resident #40 and #110. This affected three residents (#9, #40 and #110) and had the potential to affect all 126 residents residing in the facility.
Fire safety inspections
17 fire safety citations on file: 14 on August 24, 2023, 3 on January 16, 2020.
Every fire safety citation17 citations
- F
Develop Emergency Preparedness policies and procedures.
E 13 · August 24, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 24, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 24, 2023 · Corrected (the home has a date of correction)
- E
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 · August 24, 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 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · August 24, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 24, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 16, 2020 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 16, 2020 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 16, 2020 · Corrected (the home has a date of correction)