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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
3L
Actual harm
2G
0H
0I
Potential for more than minimal harm
5D
5E
0F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of hazardous materials for 1 of 68 (Resident #52) sampled for accident hazards.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders and provide care and services for oxygen therapy for 1 of 4 (Resident #7) sampled residents reviewed for respiratory care.
November 20, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure that residents received the necessary treatment and services consistent with professional standards of practice to promote healing when the facility failed to document wound care treatments for 1 of 3 (Resident #1) sampled residents reviewed for pressure ulcers.
June 30, 2021Standard inspection · 1 citation
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure respiratory equipment was stored properly and covered for 4 of 7 sampled residents (Resident #13, #28, #41, and #136) reviewed for respiratory care and 2 of 2 nurses (Licensed Practical Nurse (LPN) #3 and #4) failed to provide proper respiratory care for 1 of 1 sampled resident (Resident #22) observed for tracheostomy care.
January 22, 2020Standard inspection · 14 citations
- L
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on policy review, Maintenance Supervisor job description, User's Information Manual, review of the maintenance supervisor's logbook documentation, review of the facility's census and condition (Centers of Medicare Medicaid Services (CMS) 672), observation and interview, the facility failed to ensure the environment was free from accident hazards when hot water temperatures were measured from 116 degrees Fahrenheit (F) to 144 degrees F in 48 of 63 resident rooms (room [ROOM NUMBER], #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #210, #211, #212, #214 #217, #218, #220, #301, #302, #304, #305, #306, #307, #308, #309, #310, #311, #313, #314 #315, #317, #318, #319, #400, #401, #402, #403, #404, #405, #406, and #407). [...]
- L
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on policy review, Director of Maintenance job description, personnel file review, medical record review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to provide oversight to monitor and provide a safe resident environment related to hot water temperatures, to provide training of staff to prevent potential burns of residents when water temperatures rose to dangerous levels, to ensure injuries of unknown origin which could be indicative of abuse were identified and investigated, to ensure resident sitters were screened and trained for abuse, and to ensure coordination of care between the interdisciplinary team (IDT) to identify and assess residents' nutritional status. [...]
- L
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the Quality Assessment and Assurance policy, the Quality Assurance Plan, Administrator policy, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program when the committee did not recognize an accident hazard risk with excessively hot water temperatures in residents' rooms. The QAPI committee failed to ensure Abuse policies and procedures were followed when injuries of unknown origin which could be indicative of abuse were not identified and investigated. The QAPI committee failed to ensure resident sitters were appropriately screened for abuse, had criminal background checks, and received abuse training. The QAPI committee failed to ensure residents' nutritional status was assessed, monitored, and appropriate interventions were implemented when residents sustained severe weight loss. [...]
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure abuse screening, training, and background checks were conducted for 2 of 5 sitters (Sitter #1 and #2) which placed Resident #51 at risk for potential abuse. The facility's failure to perform screening, training, abuse registry checks, and background checks placed Resident #51 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Regional Administrator and the Regional Liaison was informed of the Immediate Jeopardy for F-600 on 1/21/2020 at 1:19 PM, in the Conference Room. The facility was cited F-600 at a scope and severity of J which is Substandard Quality of Care. An extended survey was conducted on 1/16/2020. [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to identify, thoroughly investigate, and protect vulnerable residents from further abuse for injuries of unknown source that could be indicative of abuse for 2 of 3 sampled residents (Resident #12 and #64) reviewed for abuse. The facility's failure to identify and thoroughly investigate bruising to Resident #12's left upper arm and posterior forearm and Resident #64's dark purple colored marks around the resident's neck, placed Resident #12 and #64 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy (IJ) for F-610 on 1/17/2020 at 8:15 PM, in the Conference Room. [...]
- J
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 policy review, medical record review, observation, and interview, the facility failed to ensure a Comprehensive Care Plan was developed for injuries of unknown origin and Care Plan interventions were followed for nutritional impairment for 3 of 28 sampled residents (Resident #12, #64, and #55) reviewed. The failure of the facility to develop a Comprehensive Care Plan for injuries of unknown origin that could be indicative of abuse with effective interventions and protect residents from further potential injury placed Resident #12 and #64 in Immediate Jeopardy. The failure of the facility to ensure Care Plan interventions were followed for nutritional impairment resulted in actual Harm when Resident #55 sustained severe weight loss. [...]
- G
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 policy review, medical record review, observation, and interview, the facility failed to ensure Care Plans were revised to reflect the residents' current status for severe weight loss and pressure ulcers for 3 of 28 sampled residents (Resident #55, #33, and #74) reviewed. The failure of the facility to revise the care plans for severe weight loss with effective interventions to prevent further weight loss resulted in actual Harm when Resident #55 sustained severe weight loss.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on the Registered Dietitian Service Agreement, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status, and failed to accurately assess, implement, and monitor interventions to prevent severe weight loss for 1 of 12 sampled residents (Resident #55) reviewed for weight loss. The facility's failure to identify, assess, implement, and monitor interventions to prevent severe weight loss resulted in actual Harm when Resident #55 sustained severe weight loss.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on policy review, observation, and interview, the facility failed to promote and enhance the residents' dignity when staff did not close the blinds when performing pressure injury treatments, did not knock on the residents' doors prior to entering the residents' room, and did not close the blinds when weighing a resident for 5 of 25 sampled residents (Resident #75, #30, #47. #71, and #23) reviewed.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide and document treatments for arterial wounds for 1 of 1 sampled residents (Resident #47) reviewed with arterial wounds (wounds caused by poor blood perfusion and circulation to the lower extremities).
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to document ordered treatments and accurately assess pressure ulcers for 4 of 6 sampled residents (Resident #23, #32, #56, and #74) reviewed for pressure ulcers.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on policy review, observation, and interview, the facility failed to properly store garbage in a covered dumpster on 5 of 11 days (1/15/2020, 1/17/2020, 1/18/2020, 1/20/2020, and 1/22/2020) of the survey.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to assess 2 of 2 sampled residents (Resident #36 and Resident #37) for medication self-administration.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on the medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for antipsychotic medication use, pressure injuries, and anticoagulant medication use for 3 of 28 sampled residents (Resident #21, #23, and #30) reviewed.
Fire safety inspections
23 fire safety citations on file: 1 on June 30, 2021, 22 on January 22, 2020.
Every fire safety citation23 citations
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 30, 2021 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Develop Emergency Preparedness policies and procedures.
E 13 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for sheltering.
E 22 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for volunteers.
E 24 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Establish roles under a Waiver declared by secretary.
E 26 · January 22, 2020 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · January 22, 2020 · 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 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · January 22, 2020 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 22, 2020 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 22, 2020 · 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 22, 2020 · Corrected (the home has a date of correction)
- C
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 22, 2020 · Corrected (the home has a date of correction)