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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
1E
0F
Potential for minimal harm
0A
0B
0C
April 22, 2026Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to accurately assess and monitor weight loss for one of one resident reviewed who experienced significant weight loss. (Resident R1)
June 18, 2025Standard inspection · 3 citations
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on a review of facility documents and resident clinical records and interviews with staff and resident and family member, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for one of one resident reviewed (Resident R69).
- D
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 review of facility policy, review of clinical records, interview with staff, it was determined that the facility failed to ensure comprehensive care plans were developed to address resident care needs related to a significant weight loss for one of three residents reviewed. (Resident R169)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, policy review, and staff interviews, it was determined the facility failed to develop and implement water management program for the prevention, detection, and control of water borne contaminants, such as Legionella (a bacteria that may cause lesionnaires disease, a serious type of pneumonia). Findings inlcude: Review of Centers for Disease Control and Prevention CDC guideline for Water Management in Healthcare Facilities revealed Legionella water management programs identify hazardous conditions and include taking steps to minimize the growth and spread of Legionella in the building water system. Having a water management program is now an industry standard for large buildings in the United States. [...]
September 19, 2024Standard inspection · 6 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residence records for one of 8 residents reviewed (Resident R70).
- D
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 clinical record reviews and interviews with staff, it was determined that the facility failed to notify the office of the State Long Term Care Ombudsman of facility initiated emergency transfers and facility initiated discharges for four or four facility-initiated discharges reviewed for three residents (Resident R73, Resident R74 and Resident R75)
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policies, clinical record reviews, and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of residence admission that includes the minimum healthcare information necessary to properly care for a resident for four of 16 residents reviewed (Resident R14, Resident R70, Resident R9, and Resident R120).
- D
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 review of facility policy. Review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized comprehensive care plan for two of eight residents observed (Resident 14 and Resident R70)
- D
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 review of clinical records, staff interview, and pharmacy review recommendations, it was determined that the facility failed to act on the pharmacy recommendations in a timely way for three of four residents reviewed (Resident R10, R14 and R70).
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on observations, review of facility policies, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to establish an effective infection control program related to infection surveillance and periodic review of antibiotic use.
November 3, 2023Standard inspection · 9 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on review of clinical record, facility documentation, and interview with staff it was determined that the facility failed to issue the resident/responsible party a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required for one of three resident records reviewed (Resident CL118).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview with staff and review of facility provided documentation, it was determined that the facility did not ensure that an allegation regarding nursing aide practicing administering medication was thoroughly investigated (Employee E12)
- D
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 the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, after a selected resident was transferred to the hospital for one of nine residents reviewed. (Resident R2) Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated August 29, 2023, revealed that the resident was admitted to the facility on [DATE]. Further clinical record review revealed Resident R2's responsible party was her daughter. Review of nursing note for Resident R1 dated July 29, 2023, revealed that the resident was discharged to the hospital related to a fall. [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of nine residents reviewed. (Resident R2)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R9).
- D
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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for one of nine residents reviewed. (Resident R116)
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility provided documentation, and interview with staff, it was determined that facility did not ensure to complete annual performance evaluation for two out of five nurse aides reviewed (Employee E8 and E11)
- D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on the main nursing unit.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
Fire safety inspections
21 fire safety citations on file: 5 on June 18, 2025, 6 on September 19, 2024, 10 on November 3, 2023.
Every fire safety citation21 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 18, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 18, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 18, 2025 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · June 18, 2025 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 18, 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 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 19, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 3, 2023 · 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 · November 3, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 3, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 3, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 3, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · November 3, 2023 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · November 3, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements.
K 100 · November 3, 2023 · Corrected (the home has a date of correction)
- C
Have properly located and lighted "Exit" signs.
K 293 · November 3, 2023 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 3, 2023 · Corrected (the home has a date of correction)