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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
3E
0F
Potential for minimal harm
0A
0B
0C
March 5, 2026Standard inspection, Complaint inspection · 9 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews, observations, interviews, review of manufacture's guidelines and facility policy review, the facility failed to clean a glucometer machine (a machine used to check blood sugars utilizing a drop of a person's blood). This affected one resident (#83) of five residents observed for medication administration and had the potential to affect one additional resident (#114) identified by the facility as utilizing the same glucometer. The facility also failed to follow contact precautions for Resident #5. This affected one resident (#5) of eight residents reviewed for infection control and had the potential to affect one additional resident (#60) identified by the facility as being on contact precautions. In addition, the facility failed to follow enhanced barrier precautions (EBP) for Resident #21. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on review of beneficiary notification and interview, the facility failed to ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was issued to residents discharged from a Medicare Part A stay. This affected three (Residents #118, #119, and #120) of the three discharged records reviewed for beneficiary notification. The facility census was 92.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on record review and interview, the facility failed to ensure accommodation was made for Resident #65 to participate in an activity of choice. This affected one resident (#65) of two residents reviewed for activities. The facility census was 92.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, interview review of the Stand Up (Chorus) Patient Lift Manual and facility policy review, the facility failed to provide adequate supervision/assistive devices to prevent avoidable accidents/falls. This affected one resident (Resident #10) out of four reviewed for accidents/falls. This had the potential to affect 48 residents (Resident # #3, #4, #5, #6, #10, #11, #14, #15, #17, #18, #19, #20, #23, #25, #26, #28, #30, #31, #32, #36, #38, #39, #41, #44, #46, #50, #52, #55, #57, #60, #61, #65, #70, #71, #73, #75, #77, #80, #82, #83, #84, #85, #87, #89, #95, #96, #103, #106) that required a Chorus (operated lift designed to safely transition individuals with limited mobility from sitting to standing for transfers) or mechanical lift for transfer. The facility census was 92.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure comfort measures were utilized for Resident #12. This affected one resident (#12) of three residents reviewed for pain management. The facility census was 92.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, review of the facility Controlled Mediation Shift Change Log and facility policy review, the facility failed to ensure accurate records for the receipt and disposition of controlled drugs for one of one medication cart (400 long hall) narcotic records reviewed. This had the potential to affect all residents receiving narcotic medications. The facility census was 92.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure an accurate medical record for Resident #34. This affected one resident (#34) of five residents reviewed for medication orders. The facility census was 92.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure a call light was functioning for Resident #26. This affected one resident (#26) of one resident who was investigated for a functioning call light. In addition, the facility failed to ensure the call light was within reach for Resident #3. This affected one resident (#3) of one resident who was investigated for call lights within reach. The facility census was 92.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to provide a sanitary environment for Resident #26. This affected one resident (#26) of three residents who were investigated for physical environment. The facility census was 92.
September 15, 2025Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure an allegation of verbal abuse was reported as required. This affected one resident (#68) of three residents reviewed for abuse. The facility census was 89.
December 16, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on personnel file review, narcotic destruction log review, facility policy review and interview, the facility failed to ensure a thorough investigation to prevent the possibility of drug diversion and ensure the safety of all residents after the Administrator received a text message alleging a staff member was using drugs. This had the potential to affect all residents residing in the facility. The census was 92.
April 20, 2023Standard inspection · 1 citation
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on interview, observation, review of medical record and review of Policy for Central Line Dressing Changes revealed the facility failed to ensure Resident #27's central line dressing was changed as ordered. This affected one resident (Resident #27) out of one resident reviewed in a sample of two residents, (Resident #27 and #241) with intravenous access. The facility census was 88.
December 12, 2019Standard inspection · 6 citations
- E
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, record review and policy review, the facility failed to ensure pharmacy medication review recommendations were addressed and followed up on. This affected three residents (Residents #37, #53, and #70) of five residents reviewed for use of unnecessary medications. The facility census was 71.
- E
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 interview, and record review the facility failed to ensure residents were free of unnecessary medications as their as needed psychotropic orders were not limited to 14 days and/ or a documented physician rationale was not in the resident's medical record to indicate the duration of the as needed psychotropic medication order. This affected three residents (Residents #37, #53, and #70) out of five residents reviewed for use of unnecessary medications. The facility census was 71.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, interview and policy review, the facility failed to routinely assess and monitor one resident, Resident #17, at risk for elopement. This affected one of two residents identified by the facility as having an alarming bracelet due to elopement risk. The facility census was 71 residents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview, record review and policy review, the facility failed to monitor Resident #70's bowel movements and implement bowel medications per physician orders to prevent constipation. This affected one resident (Resident #70) of one resident reviewed for constipation. The facility census was 71.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure Resident #70 were not medicated with as needed Haloperidol (anti-psychotic medication) prior to non- pharmacological interventions being attempted. This affected one of five residents reviewed for use of unnecessary medications. The facility census was 71.
- 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 interview, observation, record review and policy review, the facility failed to ensure insulin's were dated when opened for Resident #24 and Resident #46. This affected two medication carts with undated insulin for Residents #24 and Resident #46 of three medications carts reviewed for medications storage and labeling. This had the potential to affect 11 residents (Residents #11, #22, #24, #33, #36, #37, #46, #47, #65, #70 and #274) receiving insulin. The facility census was 71.
Fire safety inspections
17 fire safety citations on file: 5 on March 5, 2026, 11 on April 20, 2023, 1 on December 12, 2019.
Every fire safety citation17 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 5, 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 · March 5, 2026 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 5, 2026 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · March 5, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 5, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 20, 2023 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 20, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 20, 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 · April 20, 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 · April 20, 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 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · December 12, 2019 · Corrected (the home has a date of correction)