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 3 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
0D
1E
0F
Potential for minimal harm
0A
0B
2C
February 19, 2026Standard inspection · 2 citations
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to assess residents for side rail use, review the risks and benefits of side rail use, and obtain informed consent from the resident or responsible party for use of side rails for four of nine sampled residents. (Resident 4, 36, 37, 38)
- C
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to notify the resident's representative(s) of transfer(s), including the reasons for the moves, in writing upon transfer for three of three residents who were transferred out of the facility (Residents 1, 5, and 29) and the facility failed to provide copies of the written discharge notices to a representative of the Office of the Long-Term Care Ombudsman for three of three residents who were discharged from the facility. (Residents 2, 3, and 31)
January 15, 2025Standard inspection · 1 citation
- C
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for two of two residents who had been discharged from the facility. (Residents 1, 3)
March 7, 2024Standard inspection · 0 citations
Fire safety inspections
6 fire safety citations on file: 3 on February 19, 2026, 2 on January 15, 2025, 1 on March 7, 2024.
Every fire safety citation6 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 19, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 19, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 19, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 15, 2025 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 15, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 7, 2024 · Corrected (the home has a date of correction)