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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
6D
0E
0F
Potential for minimal harm
0A
1B
0C
September 25, 2025Standard inspection · 5 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 observation, record review, and interviews, the facility failed to prevent staff to resident abuse for one Resident (#27) of two residents reviewed for abuse. This deficient practice resulted in untreated physical pain and psychosocial harm based on the reasonable person concept.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care during functional transfers and mealtimes for two Residents (#38 and #106) of eight residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #38 experienced a fall with fracture and head contusion.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a restraint assessment, physician's order, risk-associated education, consent, and medical justification for the use of a pommel cushion were in place for one Resident (#100) of one resident reviewed for restraints.
- 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 observation, interview, and record review, the facility failed to complete and update a comprehensive care plan for one resident (Resident #38) of twenty residents reviewed for care plans.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure use of Enhanced Barrier Precautions (EBP) during high-contact resident care activities, according to current professional guidelines, for one Resident (#2) of two residents reviewed for infection control.
October 30, 2024Standard inspection · 4 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to treat three Residents (R4, R12, R31) with dignity and respect out of 18 residents reviewed for dignity. This deficient practice resulted in a lack of personal dignity and feelings of embarrassment based on the reasonable person.
- 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 interview and record review, the facility failed to develop and implement care plans for three Residents (R24, R83, and R86) of 18 residents reviewed for care planning. This deficient practice resulted in the potential for unidentified and unmet individualized resident care needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to transport two Residents (R39 and R41) in a safe manner and per standards of care out of 18 residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in the potential for injury.
- B
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, resulting in the potential for decreased quality of care for all 87 residents living in the facility.
January 10, 2024Standard inspection · 0 citations
Fire safety inspections
9 fire safety citations on file: 2 on September 25, 2025, 3 on October 30, 2024, 4 on January 10, 2024.
Every fire safety citation9 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 25, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 100 · September 25, 2025 · Corrected (the home has a date of correction)
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · October 30, 2024 · Waiver
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 30, 2024 · Corrected (the home has a date of correction)
- E
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 · October 30, 2024 · Corrected (the home has a date of correction)
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · January 10, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · January 10, 2024 · Corrected (the home has a date of correction)