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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
1E
0F
Potential for minimal harm
0A
0B
1C
May 7, 2026Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interviews with resident, family member, facility staff, agency staff and law enforcement, the facility failed to protect a resident's right to be free from misappropriation of property when $200 was transferred out of a resident's online banking account into Nurse Aide (NA) #2's personal bank account. This deficient practice affected 1 of 3 residents reviewed for misappropriation of property (Resident #1).
March 19, 2026Standard inspection, Complaint inspection · 4 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews, and resident and staff interviews, the facility failed to provide nail care for 1 of 3 dependent resident reviewed for activities of daily living (ADL) (Resident #104).
- 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 record review, observations, and resident and staff interviews, the facility failed to apply palm guards as ordered for 1 of 1 dependent resident reviewed for limited range of motion (Resident #104).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record reviews, and resident and staff interviews, the facility failed to obtain routine dental services when requested for a resident with missing upper teeth for 1 of 1 sampled resident reviewed for dental care (Resident #9).
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure nurse staffing sheets were accurate for 4 of 7 days reviewed for nurse staffing information (2/2/26, 2/9/26, 2/22/26, and 3/16/26).
March 3, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and staff, Nurse Practitioner (NP), and Responsible Party (RP) interviews, the facility failed to protect a cognitively impaired resident, Resident #6, when he was allowed to exit the facility through the locked main entrance door. Nurse Aide (NA) #1 unlocked and opened the door for Resident #6 and allowed him to leave the facility, in the dark, on the evening of 1/26/25. Resident #6 was found in the parking lot of a restaurant near a gas station 1.4 miles from the facility. There were multiple roads between the facility and where the resident was found including a divided 4 lane road, a 4-lane highway, sidewalks, posted speed limits of up to 45 miles per hour, in 38-degree Fahrenheit weather while wearing shoes, pajamas, a coat, and a hat. [...]
January 10, 2025Standard inspection, Complaint inspection · 9 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews, the facility failed to label, date, safely store food including an open box of unsealed corn on the cob, and discard expired food items that included a plastic container of partially used ice cream stored in the freezer of 1 of 1 walk-in freezers.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and interviews with staff, Nurse Practitioner (NP), and the resident's representative, the facility failed to allow a resident with behaviors to remain in the facility and to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 1 resident (Resident #205) reviewed for facility initiated discharge.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on record review, and staff and family interviews, the facility failed to ensure a safe and orderly discharge when a resident was discharged home without a referral for home health services for 1 of 2 residents reviewed for discharge (Resident #356).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews with staff, Nurse Practitioner, and the resident, the facility failed to provide care in a safe manner when a dependent resident rolled off her bed onto the floor during incontinence care. The resident was not injured. The deficient practice affected 1 of 7 residents reviewed for accidents (Resident #18).
- 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 observations, staff interviews, and facility record reviews, the facility failed to keep a urinary catheter bag and/or its tubing from touching the floor to reduce the risk of infection for 1 of 2 residents (Resident #9) reviewed for urinary catheters.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 29 opportunities, resulting in a medication error rate of 10.3% for 2 of 4 residents (Residents #32 and #86) observed during the medication administration observation.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, interviews with the staff, Nurse Practitioner (NP), and dispensing pharmacist, and hospital and facility record reviews, the facility failed to correctly transcribe an order to administer the full course of an antibiotic treatment to a resident upon her return from a hospital stay for a urinary tract infection (UTI). This occurred for 1 of 3 residents (Resident #27) reviewed for antibiotic use.
- 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 observations, interviews with staff, and record reviews, the facility failed to: 1) Store a medication in accordance with the manufacturer's storage instructions on 1 of 3 medication (med) carts observed (200 Hall Med Cart); and 2) Remove and dispose of expired medications observed to be stored in the drawer of 1 of 3 med carts observed (300 Hall Med Cart).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their infection control policy and procedure for hand hygiene when a nurse failed to perform hand hygiene after removing gloves while providing wound care for Resident #408. This occurred for 1 of 2 nurses observed for infection control practices (Nurse #3).
October 27, 2023Standard inspection · 5 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, resident, and staff interviews the facility failed to ensure the Resident's right to file a grievance and receive a written decision regarding the grievance investigation. This occurred for 1 of 1 resident reviewed for the grievance process (Resident #61).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on resident interview, staff interview, and record review the facility failed to protect resident's right to be free from abuse for 1 of 2 residents reviewed for physical abuse from Resident #48 (Resident #25). On 10/16/23 Resident #48 struck Resident #25 on the nose after a verbal altercation.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, observations, staff, and resident interviews the facility failed to accurately code Minimum Data Set assessments in the areas of Accidents and Nutrition for 2 of 6 residents reviewed (Resident #41 and #61).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to prevent a significant medication error when an additional dose of an intravenous (IV) antibiotic was administered to 1 of 1 sampled resident (Resident #27) reviewed.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, staff and resident interviews and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and interventions put into place after recertification surveys completed on 5/27/21 and 7/21/22. The deficiencies were in the areas of abuse, accuracy of assessments, residents are free from significant med errors, and accurately coding Minimum Data Set assessments and were recited on the the recertification survey of 10/27/23. The continued failure of the facility during three consecutive federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.
Fire safety inspections
11 fire safety citations on file: 2 on March 19, 2026, 5 on January 10, 2025, 4 on October 27, 2023.
Every fire safety citation11 citations
- D
Install corridor and hallway doors that block smoke.
K 363 · March 19, 2026 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · March 19, 2026 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 27, 2023 · 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 · October 27, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · October 27, 2023 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · October 27, 2023 · Corrected (the home has a date of correction)