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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
3D
0E
1F
Potential for minimal harm
0A
0B
0C
January 23, 2026Standard inspection, Complaint inspection · 4 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R157) reviewed for abuse in the sample of 42. This failure resulted in R157 fracturing her left hip which required surgical intervention and subsequently led to R157's death. Findings Include:The Facility Investigation, undated, documents the following: R136 pushed R157 causing her to fall to the floor. R157, an alert and confused female. Her BIMS (Brief Interview for Mental Status) score is 3 indicating severe cognitive impairment and her primary diagnosis is Unspecified Dementia. R157 walks independently on the unit with staff supervision. After the fall R157 complained of pain during assessment. Family and physician were notified. Resident was sent to the local hospital and was admitted with a proximal left femur fracture. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on the facility failed to implement current fall interventions for 1 (R118) of 9 resident reviewed for accidents in a sample of 42. This failure resulted in R118 sustaining a Left Patellar Fracture. Findings Include:R118's Undated Face Sheet documents R118 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia, Weakness, and Alzheimer's Disease. R118's Minimum Data Set, dated [DATE] documents R118 is severely cognitively impaired, uses a walker, and needs substantial/maximal assistance with lying to sitting on side of bed, sitting to standing, chair/bed to chair transfers, and walking 10 feet. R118's Care Plan Last Reviewed/Revised 1/15/2026 documents Problem: [...]
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff were knowledgeable and competent to utilize a deep brain stimulator (DBS) and know signs and symptoms of internal generator not charged for 1 of 1 resident (R79) in the sample of 42.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the Facility failed to evaluate swallowing function of a resident who choked a timely manner for 1 of 9 residents (R3) reviewed for accidents and hazards in the sample of 42.
September 2, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect 1 of 5 residents (R2) from abuse from (R1) when reviewed for abuse in the sample of 5. Findings Include: On 9/2/25 at 8:05 AM, R2 was observed in the dining room, calm, asked surveyor to get him some silverware, surveyor gave R2 his silverware and attempted to talk/interview R2 and R2 would not answer. R1 has been discharged from the facility. R1's Face Sheet, undated, documents R1 has the following diagnoses: Cerebral Infarction, Hemiplegia/Hemiparesis of the Right Side, Aphasia, Dysphagia, Unsteadiness on Feet, Weakness, (UTI) Urinary Tract Infection, Insomnia, HTN (Hypertension), and Hyperlipidemia. R1's MDS (Minimum Data Set), dated 8/20/25, documents R1 has a BIMS (Brief Interview of Mental Status Score) of 5, indicating R5 has severe cognitive impairment. [...]
January 23, 2025Standard inspection · 0 citations
February 15, 2024Standard inspection · 1 citation
- 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 the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen and that food was stored, prepared, and served under sanitary conditions. This has the potential to affect the 138 residents living in this facility.
Fire safety inspections
7 fire safety citations on file: 1 on January 23, 2025, 3 on February 15, 2024, 3 on December 19, 2022.
Every fire safety citation7 citations
- E
Install a two-hour-resistant firewall separation.
K 133 · January 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 · February 15, 2024 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · February 15, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 15, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 19, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 19, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 19, 2022 · Corrected (the home has a date of correction)