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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
12D
3E
0F
Potential for minimal harm
0A
0B
0C
April 24, 2026Standard inspection, Complaint inspection · 9 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to administer the correct medications for 1 of 3 sampled residents (#45) reviewed for hospitalizations. This failure resulted in Resident 45 experiencing decreased blood pressure and hospitalization.
- 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 observation and interview it was determined the facility failed to ensure medication and treatment carts were locked and secured appropriately for 1 of 4 halls observed (200 Hall) during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure hand hygiene was performed during wound care for 1 of 1 sampled resident (#7) reviewed for pressure ulcer. This placed residents at risk for cross contamination.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 1 of 1 sampled residents (#9) reviewed for accident hazards. This placed resident at risk for unsafe medication administration.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's advance directive was filed in her/his clinical record for 1 of 1 sampled resident (#5) reviewed for advance directive. This placed residents at risk for end-of-life choices not being honored.
- 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 interview and record review it was determined the facility failed to notify a resident representative after a change of condition for 1 of 1 resident (#87) reviewed for notifications. This placed residents at risk for uninformed healthcare decisions.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property for 1 of 1 sampled resident (#86) reviewed for abuse. This placed residents at risk for continued depravation of goods and services.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the State Long-Term Care Ombudsman office was notified of a resident's discharge for 1 of 1 sampled resident (#85) reviewed for discharge. This placed residents at risk for lack of advocacy.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's oxygen equipment was cleaned for 1 of 1 sampled resident (#5) reviewed for respiratory care. This placed residents at risk for decreased oxygen quality.
February 3, 2025Standard inspection, Complaint inspection · 7 citations
- K
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 4 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy situation and placed residents at risk for contracting COVID-19.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately code the MDS for 2 of 2 sampled residents (#s 6 and 65) reviewed for dental care and hospitalizations. This placed residents at risk for unmet care needs.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop and implement a care plan related to the use of hearing aids for 1 of 1 sampled resident (#269) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 1 sampled resident (#6) reviewed for skin conditions. This placed residents at risk for lack of nail care and increased infections.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#6) reviewed for PASARR (Pre-admission Screening and Resident Review). This placed residents at risk for re-traumatization and a decrease in their quality of life.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide treatment and services to correct ongoing signs of depressive behavior for 1 of 1 sampled resident (#49) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than 5%. There were two errors in 29 opportunities resulting in a 6.9% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects.
August 25, 2023Standard inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wrote1. Based on observation, interview and record review it was determined the facility failed to ensure adequate hand hygiene during medication administration for 3 of 9 sampled residents (#s 33, 41 and 161) reviewed during medication administration. This placed residents at risk for spread of infection.
Fire safety inspections
9 fire safety citations on file: 4 on April 24, 2026, 1 on February 3, 2025, 4 on August 25, 2023.
Every fire safety citation9 citations
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 24, 2026 · 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 · February 3, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 25, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 25, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 25, 2023 · 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 · August 25, 2023 · Corrected (the home has a date of correction)