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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
5E
5F
Potential for minimal harm
0A
0B
1C
October 30, 2025Complaint inspection · 1 citation
- G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on record review, review of the facility Self-Reported Incident (SRI), facility investigation review, police report review, interviews, review of the facility assessment, training review and policy review, the facility failed to ensure Resident #44 was provided appropriate and dignified dementia care to meet Resident #44's total care needs. This resulted in actual harm on 08/24/25 when Resident #44, who was identified with severe cognitive impairment with a diagnosis of dementia and required one staff assistance with activities of daily living (ADLs), received bruising to her bilateral wrists and lower forearms after her hands and wrists were held while she was combative with personal care provided by Certified Nursing Assistants (CNA) #204, #233 and #251. [...]
March 27, 2025Standard inspection · 4 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, interview, and facility policy, the facility failed to ensure a clean and sanitary kitchen as well as hair restraints were worn by kitchen staff while in the kitchen. This had the potential to affect 69 residents out of 69 who received meals from the facility kitchen. The census was 69.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure a care plan reflected a resident's current status. This affected one (#61) of one reviewed for care plans. The facility census was 69.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure resident food preferences were honored. This affected one resident (#42) of one resident reviewed for food preferences. The census was 69.
- D
Have policies on smoking.
Inspectors wroteBased on observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe manner. This affected one (Resident #50) of one resident reviewed for storage of smoking materials. The facility census was 69.
June 30, 2022Standard inspection · 17 citations
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure the menu was followed and proper portion sizes were served to residents. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interviews, and staff interviews, the facility failed to serve attractive foods at appropriate temperatures. This affected nine (Resident #9, #15, #17, #26, #27, #28, #34, #40, and #47) residents and had the potential to affect all 60 residents residing in the facility. The facility census was 60.
- 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, staff interview and policy review, the facility failed to ensure food items were stored properly with a labeled and dated to prevent food borne illness. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60.
- F
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure medical records were available to nursing staff to administer medications and treatments to residents residing in the facility. This affected all 60 residents. The facility census was 60.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to accurately code the minimum data set (MDS) assessments to reflect the status of the resident. This affected three (#63, #55, and #7) of 28 residents records reviewed. for assessments. The total facility census was 60.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote4. Record review for Resident #19 revealed an admission date of 04/08/22. Diagnosis included retention of urine. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #19 had an indwelling catheter and was always incontinent of bowel. Record review of the Critical admission assessment dated [DATE] at 1:32 A.M., completed by Registered Nurse (RN) #529, revealed the resident was admitted with a 16 french indwelling catheter. Record review revealed Resident #19 had no care plan for the indwelling catheter. Observation on 06/13/22 at 10:16 A.M., of Resident #19 revealed Resident #19 had an indwelling urinary catheter. Interview on 06/27/22 at 5:00 P.M. , with MDS Nurse #540 confirmed she was responsible to complete residents comprehensive care plans. MDS Nurse #540 verified Resident #19 had no care plan for the indwelling catheter. 5. [...]
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review the facility failed to revise comprehensive care plans according to resident needs. This affected five (#3, #4, #7, #15, and #27) of 23 residents reviewed for comprehensive care plans. The facility census was 60.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, review of hospital records, resident interview, staff interview, observation, and review of facility policy, the facility failed to assess Resident #62 for a change in condition. The facility also failed to assess and obtain physician orders for dry skin condition for Resident #43. This affected two (#62, and #43) of 23 residents reviewed for quality of care. The facility census was 60.
- E
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, resident and staff interviews, record review and review of the policy, the facility failed to safely store four (#66, #39, #47, and #32) residents medications. this had the potential to affect eight (#51, #23, #10, #45, #40, #31, #34, and #12) residents identified by the facility as being independently mobile and cognitively impairment.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of a resident. This affected one (#5) of six residents observed for call light placement. The facility census was 60.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review, Resident Assessment Instrument (RAI) Manual review, policy review and staff interviews, the facility failed to complete a significant change in status assessment in the Minimum Data Assessment (MDS) when a resident displayed a significant change in health. This affected two (#61 and #7) of 25 residents reviewed. The facility census was 60.
- 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 medical record review, resident interview, staff interview and policy review, the facility failed in involve a resident and/or a resident representative in the care planning process. This affected one (#13) of 23 residents care plans reviewed. The facility census was 60.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, review of shower sheets, and review of facility policy, the facility failed to ensure residents received assistance with showers and/or shaving as required. The facility failed to apply foot pedals to a wheel chair of a dependent resident. This affected two (#37 and #43) of three residents reviewed for Activities of Daily Living (ADLs). The facility census was 60.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure Resident #7 received audiology services in a timely manner. This affected one (#7) of one resident reviewed for hearing. The facility census was 60.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review and staff interview, the facility failed to obtain physician orders for the care and treatment of an indwelling urinary catheter. This affected one (#61) of three residents reviewed for catheter care. The facility census was 60.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to obtain weights and address significant weight loss in a timely manner for two (#61 and #7) residents. The facility failed to consistently provide fluids with meals for one (#7) resident. This affected two (#61 and #7) of two residents reviewed for nutrition and hydration. The facility census was 60.
- C
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on resident interviews, staff interview, and review of facility policy, the facility failed to ensure mail was delivered to residents on Saturdays. This affected nine (#9, #15, #17, #26, #27, #28, #34, #40, and #47) residents and had the potential to affect all 60 residents residing in the facility.
June 20, 2019Standard inspection · 1 citation
- 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 review of medical record, staff interview, and review of facility policy, the facility failed to to provide a transfer/discharge letter with appeal rights when residents were transferred/discharged from the facility. This affected one residents (#44) of three residents who were transferred/discharged from the facility. The facility also failed to notify the Ombudsman of a transfer/discharge from the facility. This affected one resident (#44) of three residents who were transferred/discharged from the facility. The facility census was 65.
Fire safety inspections
21 fire safety citations on file: 5 on March 27, 2025, 11 on June 30, 2022, 5 on June 20, 2019.
Every fire safety citation21 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · March 27, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 27, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 27, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 27, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 27, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · June 30, 2022 · Waiver
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 30, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 30, 2022 · Waiver
- F
Have simulated fire drills held at unexpected times.
K 712 · June 30, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 30, 2022 · 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 30, 2022 · 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 30, 2022 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · June 20, 2019 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 20, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 20, 2019 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 20, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 20, 2019 · Corrected (the home has a date of correction)