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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
0E
0F
Potential for minimal harm
0A
0B
0C
August 7, 2025Standard inspection, Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, record reviews, and review of facility's document titled Dressing a Wound, the facility failed to maintain infection control for two out of nine sampled residents (R) (R39 and R6). Specifically, the facility failed to maintain infection control practices during a wound care procedure for R39 and during medication administration for R6. The deficient practices had the potential to place R39 and R6 at risk of exposure to infection which had the potential to contribute to their decline in health.
March 26, 2025Complaint inspection · 2 citations
- 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 observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to implement interventions/approaches identified on the comprehensive care plan for one of four sampled Residents (R) (R2) reviewed for falls.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Occurrences and Occurrence Reduction Program, the facility failed to ensure the environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four sampled Residents (R) (R2) reviewed for falls. This deficient practice had the potential to increase the risk for falls for R2.
March 28, 2024Standard inspection · 5 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, staff and resident interviews, record review and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment, for one of 36 sampled Residents (R) (R32) reviewed for resident assessment.
- D
Provide activities to meet all resident's needs.
Inspectors wrote2. Review of R101's significant change MDS with an ARD date of 1/28/2024 located in the RAI (Resident Assessment Instrument) tab of the EMR for Section C (Cognitive Patterns) revealed R101 had a BIMS score of 12 out of 15 indicating R101's cognition was moderately impaired; Section GG (Functional Abilities and Goals) revealed upper and lower extremities were impaired on one side; Section F (Preferences for Customary Routine and Activities) revealed activity preferences included snacks between meals; Section K (Swallowing/Nutritional Status) indicated R101 had a feeding tube, and Section I (Active Diagnoses) revealed diagnoses which included hemiplegia or hemiparesis, metabolic encephalopathy, and disorientation, unspecified. Review of R101's Care Plan, dated 1/16/2023, located in the EMR under the RAI tab, revealed Problem: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff and resident interviews, record reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure oxygen therapy was used properly for one of 36 sampled Residents (R) (R220) reviewed for oxygen use.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Unnecessary Medications Use and Monitoring, the facility failed to ensure the appropriate use of antibiotic therapy for two of 36 sampled Residents (R) (R18 and R1) reviewed for unnecessary medications.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Maintenance of Medical Records, the facility failed to ensure a complete and accurate Medication Administration Record (MAR) for one of 36 sampled Residents (R) (R32).
March 2, 2023Standard inspection · 2 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and interviews, the facility failed to protect the residents right to privacy and dignity for two of four residents (R) (R#50 and R#78), by not ensuring one of three Licensed Nurse's observed during morning medication pass, knocked on residents door and asked permission before entering room to administer medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and review of facility policies titled Infection Prevention and Control Plan, and Medication Administration: General Guidelines, the facility failed to demonstrate proper infection control practices as evidenced by one of three Licensed Nurse's observed during medication administration, handling medications with her bare hands and placing them in medication cups, for administration to resident.
Fire safety inspections
5 fire safety citations on file: 3 on August 7, 2025, 1 on March 28, 2024, 1 on March 2, 2023.
Every fire safety citation5 citations
- D
Install proper backup exit lighting.
K 281 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · March 28, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 2, 2023 · Corrected (the home has a date of correction)