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
10D
1E
1F
Potential for minimal harm
0A
0B
0C
April 2, 2026Standard inspection · 5 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview, record review, and review of the facility policy, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II Pre-admission Screening and Resident Review (PASARR). Resident (R) 11 admitted to the facility on [DATE]. On 10/08/2023, a new diagnosis of schizophrenia was added, however, the facility did not initiate a new level I PASARR. This affected one (1) of one (1) resident reviewed for PASARR.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for three out of three residents, Resident (R) R5, R6 and R7.
- 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, record review, and review of facility policies, it was determined that the facility failed to ensure interventions to prevent / decrease a resident's limitation in Range of Motion (ROM) were in place for two (2) of three (3) sampled residents, R6 and R7.
- 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, interview, and review of the facility policy it was determined that the facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one sampled residents. Observations on 03/30/2026 and 03/31/2026 revealed R5's open-ended catheter tubing was loosely hanging in the trash receptacle.
March 20, 2025Standard inspection · 4 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to assure the nutritive value of food was not compromised and destroyed because of prolonged holding on a steam table. The deficient practice had the potential to affect 163 of the facility's 163 residents who consumed food from the kitchen. Observation on 03/17/2025 at 3:20 PM, revealed macaroni and cheese and greens were placed on the steam table an hour and ten minutes prior to the evening meal being served.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure infection control procedures to prevent the spread of infection were followed for 1 of 33 sampled residents, (Resident (R)139); and for all residents residing on the 900 hall/unit who used ice from the ice cooler. 1. Observation on 03/19/2025 revealed staff failed to use appropriate Personal Protective Equipment (PPE) when providing care for R139 who required Enhanced Barrier Precautions (EBP). 2. Observation on 03/18/2025 revealed staff, after overfilling a resident's used cup with ice, and then to proceed to pour the excess ice, off the top of the cup, back into the clean cooler of ice.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to promote residents' personal privacy for 1 of 5 residents sampled for wound care, out of the total sampled residents of 33, (Resident (R)87). During observation of wound care for R87 on 03/20/2025, the wound care nurse failed to close the window blind, exposing R87 to view by anyone outside within sight of the resident's window.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure treatment and care in accordance with professional standards of practice for 1 of 7 residents sampled during medication pass out of the total sample of 33, (Resident (R)4). Observation revealed medication observed under R4's bed, lying on her bedside table, and lying in her hand while she was lying on her bed with eyes closed.
March 21, 2024Complaint inspection, Infection control · 1 citation
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on interview, record review, and review of the facility policy, it was determined the facility failed to ensure the residents responsible party received a written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for one of six (6) sampled residents (Resident #1).
February 7, 2024Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview, record review and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan which included measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial well-being for one (1) of (3) three sampled residents (Resident #1). Review of Resident #1's medical record revealed the resident had an behaviors of cursing, yelling, and wandering into other resident's rooms, however, there was no behavior care plan initiated.
January 10, 2020Standard inspection · 1 citation
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered comprehensive care plan for one (1) of thirty-five (35) sampled residents. Resident #163 was receiving dialysis three (3) times per week. Interventions implemented related to receiving dialysis included communication with the dialysis center. However, there was no documented evidence that the facility coordinated care with the dialysis center for ten (10) of fifteen (15) treatments received at the dialysis center.
Fire safety inspections
17 fire safety citations on file: 8 on April 2, 2026, 6 on March 20, 2025, 3 on January 10, 2020.
Every fire safety citation17 citations
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 2, 2026 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 2, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 20, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 20, 2025 · Corrected (the home has a date of correction)
- D
Install noncombustible or limited-combustible interior walls.
K 163 · March 20, 2025 · Corrected (the home has a date of correction)
- D
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 20, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 20, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 10, 2020 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 10, 2020 · Corrected (the home has a date of correction)
- D
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · January 10, 2020 · Corrected (the home has a date of correction)