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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
2E
0F
Potential for minimal harm
0A
0B
0C
June 1, 2026Standard inspection · 1 citation
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident reviewed for hospice (Resident #11).
May 8, 2025Standard inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code a significant change Minimum Data Set (MDS) assessment in the area of special treatments, procedures, and programs for 1 of 3 residents reviewed for Dialysis treatments and Hospice care (Resident #13).
- 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 an individualized comprehensive care plan in the area of anticoagulant (blood thinner) medication use for 1 of 2 residents whose comprehensive care plans were reviewed (Resident #8).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #1 did not doff her gloves, perform hand hygiene and don clean gloves prior to applying wound treatment and a clean dressing during wound care to Resident #2. The deficient practice occurred for 1 of 9 staff members observed for infection control practices (Nurse #1).
March 14, 2024Standard inspection · 4 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, resident and staff interview the facility failed to honor resident preference and requests to eat dinner in the dining room (Resident #46, Resident #47, and Resident #39) for 3 of 3 residents reviewed for choices.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assurrance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 10/28/21. This was for one deficiency in the area of Self Determination that was originally cited on 10/28/21 recertification and complaint investigation survey and cited again during the recertification and complaint investigation survey completed on 3/14/24. The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective QAPI program.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review and resident, resident representative and staff interviews the facility failed to afford the resident and/or resident representative the right to participate in the care plan process for 2 of 3 (Resident #7 and Resident #22) residents reviewed for care plans.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for resident with mental health diagnosis upon admission and resident with new mental health diagnoses for 2 of 3 residents (Resident #9 and Resident #15) reviewed for PASRR.
Fire safety inspections
12 fire safety citations on file: 5 on May 8, 2025, 3 on March 14, 2024, 4 on August 31, 2022.
Every fire safety citation12 citations
- D
Use approved construction type or materials.
K 161 · May 8, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 8, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 8, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 8, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 8, 2025 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · March 14, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 14, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 14, 2024 · Corrected (the home has a date of correction)
- E
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · August 31, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 31, 2022 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · August 31, 2022 · 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 · August 31, 2022 · Corrected (the home has a date of correction)