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
7D
2E
3F
Potential for minimal harm
0A
0B
0C
March 11, 2026Standard inspection · 6 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 45 residents, including 13 residents in the sample. Based on observation, interview and record review the facility failed to Ensure adequate infection control practices related to clean Hoyer lift slings.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteThe facility had a census of 45 residents. The sample included 13 residents, of which five residents were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 received as-needed (PRN) Clonazepam (an antianxiety medication that would calm and relax people with excessive restlessness, nervousness and tension) without a 14 day stop date or definitive end date for use.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteThe facility had a census of 45 residents. The sample included 13 residents, with one reviewed for nutrition/hydration status. Based on observation, record review, and interview, the facility failed to update Resident (R) 11's care plan, who was at risk for elopement with a section with instructions to staff on interventions to prevent R11 from eloping.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility had a census of 45 residents. The sample included 13 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review and interview, the facility failed to provide care and services for Resident (R)29 regarding personal hygiene and grooming.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility had a census of 45 residents. The sample included 13 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility staff failed to consistently monitor Resident (R) 20's fluid intake related to a physician-ordered fluid restriction.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThe facility reported a census of 45 residents and two kitchens. Based on observation, interview, and record review, the facility failed to ensure staff served meals at safe and appetizing temperatures. This was evident by the low temperature of food items on the last meal tray (test tray) from the kitchen on 03/11/26.
May 8, 2024Standard inspection, Complaint inspection · 2 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteThe facility had a census of 42 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager (CDM) for the 42 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an error rate of five percent (%) or less, when staff failed to prime (a procedure used to remove the air from the needle and cartridge that may collect during normal use) ) insulin (a hormone that lowers the level of glucose in the blood) KwikPens (a disposable prefilled pen containing insulin) prior to administration to Resident (R) 21. This deficient practice resulted in a medication error rate of 6.06 % and placed all residents who received insulin at risk for medication errors.
November 21, 2022Standard inspection · 4 citations
- F
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteThe facility reported a census of 32 residents with 12 residents selected in the sample. The facility identified 32 residents that lacked a Care Area Assessment (CAA) and analysis findings of the triggered care areas. Based on interview and record review, the facility failed to complete the CAAs for the comprehensive assessments for the residents that resided in the facility. The deficient practice of failure to complete the care area assessment and analysis of findings of the care areas also included Resident (R) 4, R6, R8, R9, R11, and R14.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteThe facility reported a census of 32 residents, with 12 sampled, including one for accuracy of assessments in the Minimum Data Set (MDS). Based on interview and record review, the facility failed to document resident (R) 14 regarding hospice or comfort care (palliative and supportive treatment for patients who are suffering from a terminal illness).
- 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 wroteThe facility reported a census of 32 residents with 12 residents selected for review included 2 residents sampled for Bowel/Bladder/Catheter or Incontinence Care. Based on observation, interview, and record review, the facility failed to provide appropriate care of Resident (R)6's perineum (area of the body including genitals and anus) during incontinence care.
Fire safety inspections
20 fire safety citations on file: 11 on March 11, 2026, 7 on May 8, 2024, 2 on November 21, 2022.
Every fire safety citation20 citations
- F
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 11, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 11, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
K 771 · March 11, 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 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · March 11, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 11, 2026 · Corrected (the home has a date of correction)
- F
Provide a means of sharing information on occupancy/needs.
E 34 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 8, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 8, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · November 21, 2022 · Waiver
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 21, 2022 · Corrected (the home has a date of correction)