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
5D
2E
0F
Potential for minimal harm
0A
1B
0C
July 23, 2025Standard inspection · 4 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure that residents were free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for 5 (Residents #29, 142, #206, #125, and #3) of 8 residents reviewed for physical restraints out of 35 total sampled residents. Specifically, 1.) Residents #29, 142, #206, #125, and #3 were observed on multiple occasions in bed with both upper and lower half side rails raised on both sides. All 5 residents had impaired cognition; were either dependent on staff or required substantial / maximal assistance for bed mobility; and were unable to easily and voluntarily release the side rails. [...]
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure that residents admitted with a limited Range of Motion and/or mobility, are provided services and/or treatment to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility, including the provision of equipment for limited mobility. This was evident for 2 (Residents # 20 and #85) of 4 residents reviewed for Position Mobility/Limited Range of Motion, out of 35 total sampled residents. Specifically, Residents #20 and #85, who had contractures, were observed without hand rolls as ordered by the physician to improve the residents' contractures.
- D
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 observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure residents are provided comfortable and homelike environment. This was evident for 1 (Unit1) of 3 resident units observed. Specifically, Resident #93's room appeared cluttered and disorderly, with lack of storage for resident's items.
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 07/16/2025 to 07/23/2025, the facility failed to ensure the nursing staff information posting was accurate and complete. This was evident during the Nursing Staffing Task. Specifically, the daily nurse staffing information posting was missing the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.
May 16, 2023Standard inspection · 4 citations
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interviews conducted during the recertification survey 5/9/23 to 5/16/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 2 (Resident #108 and #144) of 4 residents reviewed for Resident Assessment out of a sample size of 35 residents. Specifically, the MDS assessments for Resident #108 and #144 were not submitted and transmitted within 14 days of the completion date.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments accurately reflected the resident's status. This was evident for 2 (Resident #112 and #23)of 35 sampled residents. Specifically, 1) the MDS assessment for Resident #112 did not document the resident's dialysis treatment, and 2) the MDS assessment for Resident #23 did not document the resident's Gradual Dose Reduction (GDR) status.
- 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, interview, and record review, conducted during the recertification survey from 5/9/23 to 5/16/23, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented for each resident to meet the resident's medical needs identified in the comprehensive assessment. This was evident for 1 (Resident #23) of 35 total sampled resident. Specifically, Resident #23 did not have a CCP developed to address antibiotic therapy (ABT) use for a bacterial infection in their Arteriovenous graft (AVG).
- 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 observations, record review, and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure that a resident participated in the review of their Comprehensive Care Plan (CCP, and a resident's CCP was not reviewed and revised upon each assessment. This was evident for 2 (Resident #112 and #23) of 35 total sampled residents. Specifically, 1) Resident #112 was not invited to attend CCP meetings to discuss their plan of care, and 2) Resident #23's CCP related to mood was not reviewed and revised upon each Minimum Data Set 3.0 (MDS) assessment.
October 9, 2020Standard inspection · 0 citations
Fire safety inspections
14 fire safety citations on file: 1 on July 23, 2025, 11 on May 16, 2023, 2 on October 9, 2020.
Every fire safety citation14 citations
- D
Have exits that are accessible at all times.
K 271 · July 23, 2025 · deficient, provider has
- F
Address subsistence needs for staff and patients.
E 15 · May 16, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 16, 2023 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · May 16, 2023 · Corrected (the home has a date of correction)
- F
Have proper power supply for life support equipment.
K 915 · May 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 16, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 16, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 16, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 16, 2023 · 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 16, 2023 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for sheltering.
E 22 · May 16, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 9, 2020 · deficient, provider has
- B
Use approved construction type or materials.
K 161 · October 9, 2020 · Not yet corrected