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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
0E
1F
Potential for minimal harm
0A
2B
1C
March 30, 2026Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on reviews of 2 facility reported incidents, all pertinent facility documentation and staff interview, it was determined that the facility failed to report allegations of staff to resident abuse to local law enforcement. This was found to be evident for 2 (Resident #1 and Resident #2) of 2 residents reviewed during a complaint survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on a review of facility investigative material, medical records, and interviews with facility staff, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse. This was evidenced by 1 (Resident #1) of two residents reviewed during a complaint survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on reviews of a facility investigation and record review, and staff interview, it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident of 1 (Resident #2) of 2 residents reviewed during a complaint survey.
June 23, 2025Standard inspection, Complaint inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined that the facility 1) failed to store, prepare, distribute and serve food in accordance with professional standards for food service and 2) failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was evident during the recertification/complaint survey and has the potential to affect all residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a review of beneficiary protection notification reviews, and staff interview, it was determined that the facility staff failed to ensure proper notification of discontinued Medicare coverage was provided to the resident or their responsible party (RP). This was evident for 2 (Residents #91 and #92) out of the 3 residents reviewed for Beneficiary Protection Notifications during the recertification/complaint survey.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wrote2. A review of Resident #27's clinical record revealed the resident was discharged twice to the hospital on 2/6/25 and 4/9/25. A review of the clinical record, including the electronic health record, failed to locate evidence that notification was sent to the ombudsman. The Administrator was asked to provide a list of residents whose discharge or transfer was forwarded to the ombudsman on 6/23/25. The list did not include Resident #27. The Administrator was interviewed on 6/23/25 at 1:34 PM. She was shown the provided list of transfers and discharges. This surveyor explained the need to inform the ombudsman when a resident is admitted to the hospital. She replied I understand. Those are the names I was provided as to who was discharged or transferred. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure a resident received medication according to the physician's order set parameters (a specific instruction given for administration of medication). This was evident for 1 (Resident #22) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to ensure the residents' medication regimen was free from unnecessary medication by increasing psychotropic medication dose without documentation in the record explaining the reason for an increased dose. This was evident for one (Resident # 29) of five residents selected for unnecessary medication regimen review during this recertification/complaint survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on a review of facility investigative material, medical records, and interviews with facility staff, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for a resident. This was evidenced by 1 (Resident #140) of two residents reviewed for injury of unknown origin during this recertification/complaint survey.
June 17, 2022Standard inspection · 3 citations
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift. This was evident on 6 of 7 days of the survey.
- 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 medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#155, #158, #2) of 3 residents reviewed for hospitalization.
- B
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and staff interview it was determined that physician and Nurse Practitioner progress notes were not completed and placed in the medical record after each visit. This was evident for 2 (#151, #152) of 14 finalized sampled residents during the initial certification survey.
Fire safety inspections
6 fire safety citations on file: 5 on June 23, 2025, 1 on June 17, 2022.
Every fire safety citation6 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · June 23, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 23, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 23, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 23, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 23, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 17, 2022 · Corrected (the home has a date of correction)