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
0G
0H
0I
Potential for more than minimal harm
8D
4E
1F
Potential for minimal harm
0A
0B
0C
February 27, 2026Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review it was determined the facility failed to conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. This placed residents at risk for exposure to water-borne pathogens.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident accessible outside space was free from environmental hazards for 1 of 1 memory care outdoor area reviewed for safety and failed to safely transfer 1 of 1 sampled resident (#44) reviewed for ADLs. This placed residents at risk for injury and elopement.
October 24, 2024Standard inspection, Complaint inspection · 6 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview the facility failed to ensure a clean, home-like environment for 1 of 1 memory care units and 1 of 1 dining halls observed. This placed residents at risk for lessened quality of life.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 18% with six errors in 33 opportunities. This placed residents at risk for inaccurate medication dosage and adverse consequences related to medications.
- 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 storage was free of expired biologicals for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for diminished treatment efficacy.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from physical and mental abuse by a resident for 1 of 1 resident (# 32) reviewed for abuse. This placed residents at risk for psychosocial harm.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the MDS was coded accurately related to the use of hearing devices for 1 of 2 sampled residents (#9) reviewed for hearing. This placed residents at risk for unassessed needs.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure staff assisted a resident with wearing hearing aids for 1 of 2 sampled residents (#35) reviewed for hearing. This placed residents at risk for a decline in communication.
July 29, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#7) reviewed for abuse. This placed residents at risk for abuse.
August 30, 2019Standard inspection · 4 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report an allegation of abuse to the State Survey Agency within 24 hours for 1 of 8 sampled residents (#3) for abuse. This placed residents at risk for lack of timely investigations.
- 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 interview and record review it was determined the facility failed to revise and update a care plan related to a skin impairment for 1 of 2 sampled residents (#34) reviewed for hospitalization. This placed residents at risk for unmet 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 ensure the physician was notified of repeated refusals of thyroid medication for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for adverse side effects.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow-up on pharmacist recommendations for 1 of 5 sampled residents (#35) reviewed for medications. This placed residents at risk for adverse side effects.
Fire safety inspections
18 fire safety citations on file: 3 on February 27, 2026, 12 on October 24, 2024, 3 on August 30, 2019.
Every fire safety citation18 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 27, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 27, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 27, 2026 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · October 24, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 24, 2024 · 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 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · October 24, 2024 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · August 30, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 30, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 30, 2019 · Corrected (the home has a date of correction)