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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
4E
0F
Potential for minimal harm
0A
0B
0C
February 19, 2026Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was immediately reported for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 60 residents resided in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to immediately protect a resident from the potential for further abuse for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 60 residents resided in the facility.
February 10, 2026Standard inspection · 4 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive assessment was accurate for 1 (#35) of 12 sampled residents reviewed for accurate comprehensive assessments. The DON identified 62 residents resided in the facility.
- 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 record review and interview, the facility failed to update and implement a care plan for 1 (#35) of 12 sampled residents reviewed for care plan implementation. The DON identified 62 residents resided in the facility.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing information was posted in a prominent place readily accessible to residents, staff, and visitors for 2 of 2 observations. The DON identified 62 residents resided in the facility.
- 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, record review, and interview, the facility failed to ensure expired medications/supplies were removed from 1 of 4 medication carts and 1 of 1 medication supply room observed. The DON identified 62 residents resided in the facility.
June 18, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff implemented proper infection control practices after performing incontinent care for 1 (#10) of 2 sampled residents observed for incontinent care. The director of nursing identified 56 residents resided in the facility.
August 28, 2024Standard inspection · 7 citations
- E
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review and interview, the facility failed to complete a discharge summary of the residents' stay for three (#60, 67, and #69) of three sampled residents reviewed for discharge. The DON reported 66 residents resided in the facility.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure a MRR pharmacy request to physician had been sent to the physician to be acted upon for one (#6) of five sampled residents reviewed for unnecessary medications. The DON identified 55 residents received psychotropic medications.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure: a. an as needed psychotropic medication had a 14 day stop date for one (#14), and, b. a MRR psychotropic reduction request was acted upon for one (#37) of five sampled residents reviewed for unnecessary medications. The DON identified 66 residents resided in the facility and 55 residents received psychotropic medications.
- 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 observation, record review, and interview, the facility failed to ensure the removal of expired medications and supplies were removed from the medication storage room. The DON reported 66 residents resided in the facility.
- 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 observation, record review, and interview, the facility failed to notify the physician of a new pressure ulcer for one (#4) of one sampled resident reviewed for pressure ulcers. The CMS 802 resident matrix documented two residents had pressure ulcers.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were not left at bedside for one (#49) of six sampled resident reviewed for medications. The DON identified 66 residents resided in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure EBP were implemented during incontinent care and indwelling catheter care for one (#120) of five sampled resident reviewed for infection control. The DON identified nine residents with foley catheters and 23 with EBP's in place.
July 26, 2023Standard inspection · 2 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, record review, and interview, the facility failed to develop a comprehensive care plan for antidepressant medications for one (#55) of 15 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 39 residents received antidepressant medications. The census was 68.
- 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, record review, and interview, the facility failed to ensure insulin and insulin supplies were not left unattended and in the presence of licensed/qualified staff during medication observation for one (#272) of three residents observed for medication administration. The DON identified three residents that wander about the facility.
Fire safety inspections
9 fire safety citations on file: 3 on August 28, 2024, 3 on July 26, 2023, 3 on March 9, 2020.
Every fire safety citation9 citations
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 28, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 28, 2024 · Corrected (the home has a date of correction)
- E
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 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 26, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 26, 2023 · Corrected (the home has a date of correction)
- E
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 · March 9, 2020 · Corrected (the home has a date of correction)
- E
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 9, 2020 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 9, 2020 · Corrected (the home has a date of correction)