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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
1F
Potential for minimal harm
0A
0B
2C
November 21, 2025Standard inspection · 4 citations
- F
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for eight of eight residents reviewed (Residents R9, R24, R25, R26, R28, R31, R35 and R37).
- 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, review of drug manufacturer instructions, and staff interview, it was determined that the facility failed to appropriately date and store medications in one of two nursing medication rooms (Med Room One).
- C
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of facility policy, facility documentation, clinical records and staff interview, it was determined that the facility failed to ensure that each resident's medical record included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of Influenza/Pneumococcal immunizations; and that the resident either received the Influenza/Pneumococcal immunizations or did not receive the Influenza/Pneumococcal immunizations due to medical contraindications or refusal for eight of eight residents reviewed (Resident R9, R24, R25, R26, R28, R31, R35, and R37).
- C
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on review of facility policy, facility documentation, clinical records and staff interview, it was determined that the facility failed to ensure that each resident's medical record included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of COVID-19 immunization; and that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindications or refusal for eight of eight residents reviewed (Residents R9, R24, R25, R26, R28, R31, R35, and R37).
November 15, 2024Standard inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to fully investigate an incident with injury in a timely manner for one of 10 residents reviewed (Residents R78).
December 14, 2023Standard inspection · 2 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of manufacturer's guidelines, facility records, observations, and staff interviews, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of position description and job duties and facility documentation, and staff interviews, it was determined that the facility failed to ensure that a registered nurse was employed as the Director of Nursing on a full-time basis since October 26, 2023.
Fire safety inspections
8 fire safety citations on file: 2 on November 21, 2025, 1 on November 15, 2024, 5 on December 14, 2023.
Every fire safety citation8 citations
- D
Have power receptacles that are properly grounded.
K 912 · November 21, 2025 · Corrected (the home has a date of correction)
- B
Ensure proper usage of power strips and extension cords.
K 920 · November 21, 2025 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · November 15, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · December 14, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · December 14, 2023 · Corrected (the home has a date of correction)
- B
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 14, 2023 · Corrected (the home has a date of correction)