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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
4E
0F
Potential for minimal harm
0A
0B
0C
June 18, 2026Standard inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a physician's order was obtained to administer oxygen therapy per standard of practice for 1 of 3 residents, Resident #12, reviewed for respiratory care.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to document oxygen administration on the medication administration record per policy and procedure for 2 of 3 residents, Resident #6 and #33, reviewed for respiratory care.
May 20, 2026Complaint inspection · 1 citation
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on interview and record review the facility failed to implement corrective actions to preserve 1 resident's, Resident #1, of 3 residents reviewed, dignity following an incident during which the resident expressed dissatisfaction following an interaction with a facility staff member.
February 6, 2025Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 (Resident #55) of 4 residents reviewed for discharge assessments.
- 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 record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways.
May 21, 2024Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to inform the resident representative following a change in the resident's condition for 1 of 3 sampled residents, Resident #1.
October 26, 2023Standard inspection · 9 citations
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were transmitted within 14 days of completion for 5 of 6 residents reviewed for resident assessments, Residents #4, #28, #36, #42, and #48.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were stored in accordance with professional standards in the kitchen freezer and in 1 of 1 nourishment rooms.
- E
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 and interview, the facility failed to ensure resident records were complete and accurate for 4 of 10 residents reviewed, Residents #12, #17, #24, and #110.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control standards of practice specific to hand hygiene during medication administration and cleansing of automated blood pressure wrist cuff and oxygen saturation probe monitor during direct care.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 3 sampled residents, Resident #58.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 3 residents sampled for activities of daily living, Resident #110.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the residents received Midline intravenous catheter site dressing care and services in accordance with professional standards of practice for 1 of 1 resident receiving intravenous therapy, Resident #12 (photographic evidence obtained).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 34.38%.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and interview, the facility failed to obtain laboratory service ordered by the physician for 1 of 3 residents reviewed for laboratory services, Resident #2.
Fire safety inspections
16 fire safety citations on file: 8 on June 18, 2026, 3 on February 6, 2025, 5 on October 26, 2023.
Every fire safety citation16 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 18, 2026 · 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 · June 18, 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 · June 18, 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 · June 18, 2026 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 18, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 18, 2026 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · June 18, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 18, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 6, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 26, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 26, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 26, 2023 · Corrected (the home has a date of correction)