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 13 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
0E
1F
Potential for minimal harm
0A
0B
0C
May 13, 2026Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observations, and interview, the facility failed to maintain infection control practices for 1 resident (Resident #204) of 4 residents reviewed for urinary catheters.
July 17, 2024Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility policy review, facility investigation documentation review, observation, and interview the facility failed to protect 1 Resident (Resident #13) from physical abuse of 7 residents reviewed for abuse.
December 20, 2023Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to report the suspicion of a crime for 1 resident (Resident #1) of 1 resident reviewed to the State Survey Agency, local law enforcement, adult protective services, and other officials (where state law provides for jurisdiction in long-term care facilities) in accordance with State law.
October 26, 2022Standard inspection · 7 citations
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on facility policy review, review of the facility's 2567 dated 9/18/2019 and 9/22/2021, medical record review, observations, and interviews, the facility's Quality Assurance Performance Improvement (QAPI) program failed to have an effective system in place to sustain compliance with ensuring residents were free from abuse and reporting allegations of abuse for 1 resident (#58) of 24 residents reviewed for abuse. The QAPI committee's failure to effectively monitor previously identified deficient practices and corrective actions to ensure residents were free of abuse and reporting allegations of abuse had the potential to affect all 162 residents in the facility.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to protect 1 resident (Resident #58) from abuse of 24 residents reviewed for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse after a resident-to-resident altercation for 2 residents (Resident #58 and Resident #67) of 24 residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 1 resident (Resident #58) of 24 residents reviewed for abuse.
- 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 wroteBased on facility policy review, medical record review, and interview, the facility failed to revise the care plan after the code status (Resident's wishes for treatment if the heartbeat or breathing stops) changed for 1 resident (Resident #63) of 32 residents reviewed for care plans.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to assist with care of a colostomy according to the resident's preferences for 1 resident (Resident #446) of 32 residents reviewed for activities of daily living (ADLs).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of the facility policy, medical record review, observation, and interview, the facility failed to administer medications through a Percutaneous Endoscopic Gastrostomy (PEG) enteral tube (tube inserted into the abdomen used for nutrition and medications) as ordered by the physician for 1 resident (Resident #40) of 8 residents with enteral tubes.
September 18, 2019Standard inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility abuse policy, medical record review, review of facility documentation, observation and interview, the facility failed to prevent verbal abuse of 1 resident (#17) of 26 residents reviewed for abuse.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one resident (#19) of 3 residents reviewed for discharge MDS assessments.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, facility documentation review and interview, the facility failed to ensure unnecessary medications were not administered to 1 resident (#82) of 6 residents reviewed for unnecessary medications.
Fire safety inspections
5 fire safety citations on file: 3 on May 13, 2026, 2 on October 26, 2022.
Every fire safety citation5 citations
- D
Have an enclosure around a vertical opening shaft.
K 311 · May 13, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 13, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 13, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 26, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 26, 2022 · Corrected (the home has a date of correction)