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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
0E
0F
Potential for minimal harm
0A
0B
0C
January 16, 2026Standard inspection · 3 citations
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the responsible party was involved in decisions related to the resident's day to day activities for 1 of 1 sampled resident (#46) reviewed for resident rights and care planning. This placed residents at risk for their representatives not being informed of the resident's health status.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure ordered services were obtained to increase ROM for 1 of 2 sampled residents (#46) reviewed for mobility and choices. This placed residents at risk for decreased mobility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined the facility failed to perform hand hygiene for 1 of 1 sampled resident (#6) reviewed for pressure ulcers. This placed the resident at risk for cross contamination.
September 26, 2024Standard inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for adverse medication side effects.
February 26, 2024Complaint inspection · 2 citations
- 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's representative timely of a change of condition for 1 of 3 (#3) sampled residents reviewed for resident rights. This placed residents at risk for delayed treatment.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure staff had the appropriate skills and competencies necessary to care for resident needs related to external catheter devices for 1 of 3 sampled residents (#3) reviewed for incontinence care. This placed residents at risk for unmet needs.
June 16, 2023Standard inspection · 6 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure call lights were within reach for 1 of 4 sampled residents (#1) reviewed for accommodation of need. This placed residents at risk for lack of ADL care.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide nail care for 2 of 4 sampled residents (#s 15 and 16) reviewed for activities of daily living. This placed residents at risk for unmet nail care needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#20) reviewed for unnecessary medications. This placed residents at risk for improper administration.
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 1 of 4 sampled residents (#1) reviewed for accommodation of need and staffing. This placed residents at risk for unmet ADL care needs.
- 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 and interview it was determined the facility failed to secure a treatment cart for 1 of 3 halls observed for medication storage. This placed residents at risk for lost or missing medications.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident self-administration of medication assessment records were complete and accurate for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for inaccurate medication assessments.
Fire safety inspections
8 fire safety citations on file: 3 on January 16, 2026, 2 on September 26, 2024, 3 on June 16, 2023.
Every fire safety citation8 citations
- F
Address patient/client population and determine types of services needed.
E 7 · January 16, 2026 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · January 16, 2026 · 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 · January 16, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 26, 2024 · 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 · September 26, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 16, 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 · June 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 16, 2023 · Corrected (the home has a date of correction)