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 16 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
2E
2F
Potential for minimal harm
0A
0B
0C
March 25, 2026Standard inspection, Complaint inspection · 6 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate notice of non-coverage and maintain documentation for two residents (Resident #33 and Resident #78) of 3 residents.
- D
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 provide a homelike environment for 11 rooms of 11 rooms reviewed for cleanliness and maintain comfortable temperatures in the Memory Care Unit.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis citation pertains to intake 2634030. Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on interview, and record review, the facility failed to prevent misappropriation of money for 1 (R34) of 2 residents reviewed for misappropriation.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThis citation pertains to intake 2634030. Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on interview and record review, the facility failed to follow policies and procedures to report misappropriation of resident money for 1 (R34) of two residents reviewed for misappropriation.
- D
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 the facility failed to ensure safe transfer practices for 1 resident (R94) of 3 residents reviewed for accidents and falls.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to 1) maintain proper enhanced barrier precautions for two residents (R14 and R41) of 5 residents reviewed and 2) fully implement a water management plan.
August 29, 2025Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteThis citation pertains to Intake #2566577 and #2575897. Based on interview and record review, the facility failed to ensure dignified care was provided for 2 residents (R100 and R101) of 4 residents reviewed for dignity.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to Intake #2575897. Based on interview and record review, the facility failed to provide showers for 2 dependent residents (R101 and R103) of 4 residents reviewed for accommodation of needs.
March 6, 2025Standard inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a) Accurate monthly infection surveillance, b) Conduct an outbreak investigation, and c) Properly store oxygen supplies according to the facility Infection Control plan, program and policies for one resident (R25) of six residents reviewed for Infection Control.
- 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, the facility failed to investigate, analyze, and implement meaningful interventions to prevent repeated falls for two Residents (R32 and R117) of three residents reviewed for accident hazards.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to follow it's Antibiotic Stewardship policy for two residents (R1 & R64) out of 16 residents reviewed for antibiotic stewardship.
- D
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 interview and record review, the facility failed to administer a COVID-19 vaccine after receiving consent for the vaccine for two residents (R12 and R29), out of 5 residents reviewed for immunizations.
March 6, 2024Standard inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThis citation has 2 Deficient Practice Statements (DPS) DPS 1 Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 5 of 8 residents (Resident #17, #23, #43, #46, and #62), reviewed for the provision of nursing services, resulting in lack of vital sign and blood sugar assessments prior to medication administration, medications improperly administered, and management of controlled substances.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy for pressure injury/wound management for 1 out of 6 residents (Resident #41) reviewed for pressure injury monitoring and treatment, resulting in incomplete and late wound assessments.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adherence to proper medication administration guidelines for two Residents (R15 and R62) resulting in a medication administration error rate of greater than five percent. Findings Resident #15 (R15) Review of the medical record reflected R15 originally admitted to the facility 7/28/19 and a pertinent diagnosis of End Stage Renal Disease (ERSD) and is on Hemodialysis. Review of the Doctor's Orders for R15 revealed an order for Sevelamer Oral Tablets 800 milligram (mg) Give 2 tablet by mouth before meals for high phosphorous levels. On 3/5/24 at 8:10 AM a medication administration observation was conducted with Licensed Practical Nurse (LPN) F. LPN F was observed to administer 2 tabs of Sevelamer 800 milligrams ordered to be given before meals to R15. R15 reported she had eaten her breakfast earlier. [...]
Fire safety inspections
19 fire safety citations on file: 17 on March 25, 2026, 2 on March 6, 2025.
Every fire safety citation19 citations
- F
Include a process for Emergency Preparedness collaboration.
E 9 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · March 25, 2026 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 25, 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 25, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 25, 2026 · Corrected (the home has a date of correction)
- E
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 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 25, 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 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · March 25, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 6, 2025 · 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 6, 2025 · Corrected (the home has a date of correction)