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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
0E
0F
Potential for minimal harm
0A
2B
1C
July 30, 2025Standard inspection, Complaint inspection · 7 citations
- 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 and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when Resident #86 requested toileting assistance from Nurse Aide (NA) #1 to use the bed pan for a bowel movement and the NA told the resident to have a bowel movement in his brief. A reasonable person expects to be assisted with toileting needs by their caregiver and would have experienced embarrassment when told to have a bowel movement in their brief rather than be assisted with toileting needs as requested. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #86).
- 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 observations, record review, and staff, resident, and Medical Director interviews, the facility failed to notify the physician of a significant change when the resident's feeding tube site was identified by staff as visibly irritated, leaking, and caused the resident pain when touched for 1 of 1 sampled resident reviewed for feeding tube care (Resident #64).
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, staff and resident interviews, Pharmacy Manager and Medical Director interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 2 of 3 residents reviewed for misappropriation of property (Resident #96 and Resident #18).
- 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 staff interviews, the facility failed to develop a care plan for 1 of 5 residents reviewed for psychotropic medications (Resident #2).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, and staff, Pharmacy Manager, and Medical Director interviews, the facility failed to have effective systems in place for the inventory of controlled substances which resulted in a narcotic medication being ordered for a resident that did not have a physician order and the medication being diverted from the facility for 1 of 3 residents reviewed for misappropriation of resident's property (Resident #96).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain an accurate medication administration record for 1 of 5 residents reviewed for medication administration (Resident #36).
- B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and resident and staff interviews, the facility failed to notify the Ombudsman in writing of an unplanned discharge to home for 1 of 3 residents reviewed for discharge (Resident #68). In addition, the facility failed to notify the Resident Representative in writing of the reason for the transfer/discharge to the hospital and failed to provide a copy of the bed hold policy to the resident and Resident Representative for 3 of 4 residents reviewed for hospitalization (Resident #5, Resident #36, and Resident #54).
May 22, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, and staff and Medical Doctor interviews, the facility failed to enter a physician's order into the electronic medical record and document the administration of a medication for 1 of 4 residents reviewed for medication administration documentation (Resident #1).
June 13, 2024Standard inspection, Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to maintain dignity when a resident had an uncovered urinary drainage bag with urine visible for public view from the hallway. The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want their urine visible to visitors, staff, and other residents. This deficient practice was for 1 of 3 residents reviewed for dignity. (Resident #213)
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews with staff and record review the facility failed to complete a baseline care plan within 48 hours of admission to address the immediate needs for 1 of 3 newly admitted residents reviewed (Resident #213).
February 9, 2023Standard inspection · 4 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 record review and staff interview the facility failed to implement a comprehensive care plan for 1 of 1 resident who received renal dialysis (Resident #43).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and staff interviews the facility failed to ensure a resident receiving dialysis had a physician's order for 1 of 1 sampled resident reviewed for receiving dialysis. (Resident #43).
- C
Post nurse staffing information every day.
Inspectors wroteBased on staff interviews and record reviews, the facility failed to post accurate Daily Nurse Staffing Information that reflected the Daily Shift Assignment for licensed nurses for 6 out of 30 days.
- B
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, the facility failed to (1)maintain drywall in good repair as evidenced by drywall that was scratched and peeling off the wall behind resident beds and adjacent walls in occupied resident rooms for (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), 2) ensure privacy curtains were free of stains (room [ROOM NUMBER] and room [ROOM NUMBER]), and 3) and ensure a tube feeding pump, a tube feeding pole, and suction equipment were in clean and sanitary condition (room [ROOM NUMBER]) for 3 of 4 halls observed.
Fire safety inspections
12 fire safety citations on file: 9 on June 13, 2024, 3 on February 9, 2023.
Every fire safety citation12 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 13, 2024 · 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 · June 13, 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 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · June 13, 2024 · 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 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 13, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · June 13, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · June 13, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 9, 2023 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 9, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 9, 2023 · Corrected (the home has a date of correction)