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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
14D
1E
0F
Potential for minimal harm
0A
0B
0C
May 12, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remained free of accident hazards as is possible for (1) one of (3) three current sampled residents, Resident #1, resulting in harm. While operating a motorized wheelchair in the facility parking lot on 4/03/26, Resident #1 struck a curb which caused the motorized wheelchair to tilt resulting in Resident #1 falling from the motorized wheelchair. Resident #1 sustained bilateral subdural hematomas, first/second cervical vertebral fractures, a scalp laceration, multiple abrasions, and a hematoma of the scalp resulting in transfer to a higher level of care and surgical intervention.
September 22, 2023Standard inspection, Complaint inspection · 10 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and staff interview, facility staff failed to ensure the privacy and confidentiality of medical information in oral communication for 1 of 30 current residents in the survey sample, Resident #51. Resident #51 was admitted to the facility with diagnoses that included peripheral vascular disease and renal failure. On the Minimum Data Set assessment with Assessment Reference Date 7/12/23, the resident scored 10/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident was unaware that staff were shouting details about the resident's clinical condition in the hall. On 9/19/23 at 9:20 AM, CNA#5 yelled down the hall to LPN #1 you got any Foleys on that hall? LPN #1 replied there's no one named Foley on this hall. CNA #5 then yelled Foley catheters. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to accurately code a minimum data set (MDS) assessment for 1 of 3 closed records reviewed, Resident #112.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. For Resident #96, the facility staff failed to ensure fall prevention and safety measures were in place per the resident's comprehensive person-centered care plan. Resident #96's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Non-traumatic Subarachnoid Hemorrhage, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Cirrhosis of the Liver. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/05/23 coded the resident as moderately impaired in cognitive skills for daily decision making with short-term memory problems. Resident #96 was coded as requiring extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene and being totally dependent on staff for transfers. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that the resident environment remained as free of accident hazards as is possible as evidenced by the presence of unsecured oxygen cylinders located in 2 of 30 resident rooms in the survey sample, Resident #267 and #271.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure that a resident who needs respiratory care is provided such care consistent with the comprehensive person-centered care plan for 1 of 30 residents in the survey sample, Resident #40.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, clinical record review, facility document review and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5 %. There were three errors in 36 opportunities for a medication error rate of 8.3%. These errors affected Resident # 40.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interviews, and clinical record review, the facility staff failed to ensure medications were secure and stored in locked compartments for 1 of 30 residents in the survey sample, Resident #264.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 30 residents in the survey sample, Resident #267.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 30 residents in the survey sample, Resident #264.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, and facility document review, the facility staff failed to maintain an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of COVID-19 on 1 of 2 nursing units, Unit 2. Facility staff failed to follow facility policy and procedure and CDC (Centers for Disease Control and Prevention) guidance related to source control mask use during a COVID-19 outbreak. At the time of the survey on 9/21/23, there was a current facility total of 40 COVID-19 positive residents and 27 COVID-19 positive staff members. Unit 2 had a total of 18 COVID-19 positive residents.
July 22, 2021Standard inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 1 of 26 residents in the survey sample, Resident #74.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure that residents were free of significant medication errors for 1 of 26 residents in the survey sample, Resident #50.
September 20, 2018Standard inspection · 3 citations
- E
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 staff interview, clinical record review, and facility document review, pharmacy staff failed to submit irregularity reports to the facility director of nursing and medical director for action for 4 of 34 residents sampled (Resident #57, 72, 95, and 101). The Findings Included: 1. For resident #57, pharmacy staff failed to submit a pharmacy irregularity report recommending laboratory testing. Resident #57 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, heart failure, hypertension, gastroesophageal reflux, thyroid disorder, arthritis, osteoporosis, fracture leg, malnutrition, anxiety, depression, and insomnia. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 34 residents (Resident #9).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure a complete and accurate clinical record was maintained for 1 of 34 residents (Resident #6).
Fire safety inspections
15 fire safety citations on file: 3 on September 22, 2023, 12 on July 22, 2021.
Every fire safety citation15 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 22, 2023 · Corrected (the home has a date of correction)
- E
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · September 22, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 22, 2023 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · July 22, 2021 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 22, 2021 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · July 22, 2021 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · July 22, 2021 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 22, 2021 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 22, 2021 · Waiver
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 22, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 22, 2021 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · July 22, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 22, 2021 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · July 22, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 22, 2021 · Corrected (the home has a date of correction)