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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
2E
0F
Potential for minimal harm
0A
1B
0C
June 26, 2026Standard inspection, Complaint inspection · 4 citations
- E
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 and staff interviews, the facility failed to remove expired medications stored in 1 of 3 medication rooms and 1 of 6 medication carts reviewed for medication storage (Over the Counter (OTC) Medication Storage Room and Medication Cart for 800 hall).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, staff and resident interviews, the facility failed to provide a resident with dignity and respect when Nurse Aide (NA) #1 confronted Resident #77 about reporting her and making false accusations to management. Resident #77 stated this made her feel fearful and treated unfairly. The facility also failed to provide dignity and respect to Resident #35 when NA #2 spoke smack and not very nice to the resident. Resident #35 stated this made him feel frustrated. This occurred for 2 of 4 residents reviewed for dignity (Resident #77 and Resident #35).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff and Physician interviews, and record review, the facility failed to implement their infection control policy and procedure, when a Nurse Aide (NA) failed to perform hand hygiene after the completion of catheter care for Resident #36 who was on Enhanced Barrier Precautions (EBP) for an indwelling catheter. This deficiency occurred for 1 of 4 staff members reviewed for infection control practices (NA #4).
- B
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of Resident Council meeting minutes, resident and staff interviews, the facility failed to implement an effective process to resolve and communicate the facility's efforts to address repeated concerns by residents related to lack of weekend housekeeping and unlabeled/missing clothing items, for 2 of 5 months of Resident Council meetings (May 2026 and June 2026).
November 19, 2025Complaint inspection · 1 citation
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on facility record review, hospital emergency department record review, and Resident, Responsible Party, staff, and Medical Director Interviews, the facility failed to ensure a resident received the medications ordered for her by the physician at discharge from the facility. At the time of discharge on [DATE] medications belonging to another resident were inadvertently provided to Resident #1. On 10/21/25 the Responsible Party looked at the medication packaging and realized the medications were prescribed for another resident and she was taken to the Emergency Department (ED) for evaluation. The ED Provider Note stated Resident #1 had no complaints, but the RP stated she was shaky over the last few days. [...]
April 3, 2025Standard inspection, Complaint inspection · 4 citations
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman, the residents and/or the resident representatives in writing of a resident transfer for 2 of 3 residents reviewed for hospitalization (Resident #88 and Resident #81).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interviews and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of active diagnoses and urinary catheter for 2 of 20 residents reviewed for MDS accuracy (Residents #39 and #100).
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record review and staff, Wound Care Physician, and lab vendor interviews, the facility failed to notify the Wound Care Physician of a positive wound culture lab result when it was reported to the facility which delayed initiating antibiotics for 3 days. This deficient practice affected 1 of 2 sampled residents (Resident #53).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation and interviews of the staff and wound care physician, the facility failed to follow their infection control policy for hand hygiene and glove use when the Wound Care Nurse did not perform hygiene and don new gloves after the dirty portion of the pressure ulcer dressing change and before beginning the clean portion of the dressing change (Resident #53). This deficient practice occurred for 1 of 2 staff observed for infection control practices.
January 11, 2024Standard inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide (NA) #1 and NA #2 failed to remove their masks before exiting a COVID-19 isolation room for 2 of 7 residents reviewed for infection control. (Resident #10 and Resident #24)
Fire safety inspections
4 fire safety citations on file: 1 on April 3, 2025, 2 on January 11, 2024, 1 on September 2, 2022.
Every fire safety citation4 citations
- 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 · April 3, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 11, 2024 · 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 11, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 2, 2022 · Corrected (the home has a date of correction)