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 9 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
1E
0F
Potential for minimal harm
0A
1B
0C
April 16, 2026Standard inspection · 0 citations
February 27, 2025Standard inspection · 6 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 19 residents reviewed for advanced directives (Resident #62).
- 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), level II was completed after a readmission with mental health diagnoses for 1 of 3 residents (Resident #40) reviewed for PASRR.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide toenail care to 1 of 2 residents (Resident #82) who were dependent on staff for assistance with activities of daily living (ADL).
- D
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 interviews with staff, Consultant Pharmacist, and Nurse Practitioners, the facility failed to respond to identified drug irregularities related to the use of as needed (PRN) psychotropic drug (drug that affects mental state) and provide follow up recommendations for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #83).
- D
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 interviews with staff and Nurse Practitioners, the facility failed to ensure physician's orders for as needed (PRN) psychotropic drug (drug that affects mental state) was time limited in duration and provided rationales for therapy exceeding 14 days for 1 of 5 sampled residents reviewed for unnecessary medications (Residents #83).
- B
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, resident, staff, and responsible party (RP) interviews the facility failed to notify the resident and the Responsible Party in writing of transfers to the hospital for 2 of 2 residents reviewed for facility initiated discharge (Resident #6 and Resident #55).
January 5, 2024Standard inspection · 3 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and/or failed to remove expired food items in 1 of 2 nourishment rooms (300 Hall). These practices had the potential to affect food served to residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of hospice services, seizure disorder, and discharge for 3 of 6 residents whose MDS assessments were reviewed (Resident #15, # 205 and #83). Findings Include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included end stage renal failure. Review of Resident #15's care plan initiated on 11/09/23 for Hospice care with interventions that included Hospice services provided, facility to work with Hospice team and continue to make Resident #15 comfortable. The admission MDS assessment dated [DATE] indicated Resident #15 was moderately cognitively impaired. He was not coded for receiving Hospice services both while a resident and while not a resident. [...]
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 08/12/21 and 08/25/22. This was for one deficiency cited in August 2021 and August 2022 in the area of Accuracy of Assessments and subsequently cited on the current recertification and complaint investigation survey of 01/05/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.
Fire safety inspections
5 fire safety citations on file: 1 on April 16, 2026, 3 on February 27, 2025, 1 on January 5, 2024.
Every fire safety citation5 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2026 · Not yet corrected
- D
Use approved construction type or materials.
K 161 · February 27, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 27, 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 · February 27, 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 · January 5, 2024 · Corrected (the home has a date of correction)