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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
1F
Potential for minimal harm
0A
0B
1C
November 17, 2025Standard inspection · 2 citations
- 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, record review and facility policy review, the facility failed to ensure drugs and biologicals were current for use and/or labeled in accordance with currently accepted professional principles, including the expiration date when applicable, for 2 of 3 medication carts reviewed and for a total of 6 out of 13 sampled residents (Resident (R)5, R8, R17, R18, R30, and R39).
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to post staffing data as required for 3 of the 3 State Survey Agency's (SSA's) survey dates.
September 8, 2023Standard inspection, Complaint inspection · 3 citations
- 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 Care Plan (CCP) for one (1) of six (6) sampled residents (Resident #25). Observations and record review revealed Resident #25 had an indwelling urinary catheter, however, there was no documented evidence a care plan had been implemented to include catheter care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined 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 two of six (6) sampled residents (Resident #7 and Resident #25). Observations of Resident #7 and #25, on 09/06/2023 and 09/07/2023, revealed the resident's catheter bags were not properly secured and were touching the floor.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, facility policy review and review of the facility's investigation, it was determined the facility failed to ensure one (1) of six (6) sampled residents received adequate supervision to prevent elopement from the facility. Record review revealed Resident #18 exited the facility through the front door as an employee was leaving for lunch on 07/07/2023. Resident #18 exited the facility on 07/07/2023 at approximately 1:30 PM. After the incident, the Wander Risk Assessment was completed again at which time the resident scored six to eleven (6-11) points, which indicated the resident had a moderate risk and the need for an Elopement Care Plan which was initiated with interventions put into place.
December 8, 2021Standard inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, facility policy review and review of the Centers for Disease Control (CDC) documentation, it was determined the facility failed to maintain its infection control and prevention program in accordance with CDC guidelines for COVID-19. CDC guidelines stated for counties with substantial or high transmission rates of COVID-19, staff were to wear eye protection when caring for patients (residents). The facility failed to ensure its staff wore the appropriate eye protection during all patient encounters as indicated in the CDC guidance. The deficient practice had the potential to affect all residents residing in the facility.
Fire safety inspections
9 fire safety citations on file: 3 on November 17, 2025, 5 on September 8, 2023, 1 on December 8, 2021.
Every fire safety citation9 citations
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · November 17, 2025 · Corrected (the home has a date of correction)
- D
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 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 17, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · September 8, 2023 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 8, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · December 8, 2021 · Corrected (the home has a date of correction)