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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
12D
1E
2F
Potential for minimal harm
0A
0B
1C
March 26, 2026Standard inspection, Complaint inspection · 3 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, and Responsible Party (RP) and staff interviews, the facility failed to provide written grievance summaries for 4 grievances filed by Resident #136's responsible party. The deficient practice occurred for 1 of 1 resident reviewed for grievances (Resident #136).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of use of anticonvulsant medication for 1 of 39 residents whose MDS assessments were reviewed (Resident #128).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for 1 of 39 residents reviewed for accurate medical records (Resident #139).
December 19, 2024Standard inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of vision (Resident #69), and for the use of a wander elopement alarm and hypoglycemic (medications that help lower blood sugar levels in people with diabetes) medication (Resident #74) for 2 of 26 residents whose MDS assessments were reviewed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to change the disposable inner cannula for 1 of 1 resident observed for tracheostomy care (Resident #111).
- D
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 observations, record review and staff interviews, the facility failed to: discard expired zinc supplement tablets for 1 of 2 medication rooms (Unit 3 Medication Storage Room), discard an opened bottle of aspirin that had no expiration date for 1 of 3 medication carts (4 B Medication Cart), and dispose of loose and unidentified pills for 2 of 3 medication carts (Medication Cart 3A and Medication Cart 4B) reviewed for medication storage.
October 12, 2023Standard inspection, Complaint inspection · 12 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, resident interviews, and staff interviews, the facility failed to safely transport a resident back to her room via wheelchair (Resident #5) when she requested to be put back to bed. Resident #5's left leg got caught under the left side of her wheelchair without leg rests attached while being pushed by a Nurse Aide (NA) and resulted in a nondisplaced fracture of the left proximal (near the center of the body) tibial (shinbone) metaphysis (neck portion of the long bone) and plateau (cartilage that covers the top end of the tibia). As a result, the resident endured acute (short-term) pain that was treated with medication. This was for 1 of 4 residents reviewed for accidents (Resident #5).
- G
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, record review, and interviews with resident and staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in order to sustain compliance. This included a recited deficiency in the area of Supervision to Prevent Accidents (F689) as evidenced by repeat citations resulting in harm to residents. During the [DATE] recertification and complaint investigation survey, deficient practice at F689 resulted in the resident sustaining a spleen laceration, subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) and rib fractures. [...]
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interviews, the facility failed to maintain the area surrounding the dumpsters free of debris and failed to close the doors to dumpsters that contained waste for 2 of 3 dumpsters observed. This practice had the potential to attract pests and rodents.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on record review and staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on record review, staff interviews, and Responsible Party (RP) interview, the facility failed to provide an ongoing resident centered activities program that included activities to meet the interests of a resident that did not participate in group activities for 1 of 1 residents reviewed for activities (Resident #100).
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to invite the resident or resident responsible party to participate in the care planning process for 1 of 27 residents whose care plans were reviewed (Resident #77).
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to honor a resident's bathing preference when showers were not provided as scheduled for 1 of 4 dependent residents (Resident #71) reviewed for choices
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a new antidepressant medication and placement of an alert bracelet (an elopement alarm) for 1 of 1 resident reviewed for notification of change (Resident #109).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation. The active physician's orders revealed an order dated 5/17/2023 for Eliquis (anticoagulant medication) tablet 5 milligrams twice a day at 8am/8pm. Resident #53's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was moderately cognitively impaired and coded for anticoagulant medication. The active comprehensive care plan last reviewed on 8/10/2023 revealed anticoagulant medication therapy was not referenced in the care plan. During an interview with the MDS Nurse #1 on 10/10/2023 at 12:38 P.M. she revealed she was not sure how she forgot to document Resident #53's anticoagulant therapy on the care plan during the quarterly review of the plan. An interview was conducted with the Director of Nursing (DON) on 10/11/2023 at 9:31 A.M. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #109).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to remove soiled gloves before placing a clean inner cannula in Resident #95's tracheostomy (surgical opening in windpipe for air/oxygen) for 1 of 1 residents reviewed for tracheostomy care.
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interviews, the facility failed to 1) post accurate licensed nurse staffing data for 10 of 10 days reviewed for sufficient staffing (10/01/23-10/10/23), and 2) failed to post accurate census data for 2 of the 4 days during the survey (10/09/23 and 10/10/23).
Fire safety inspections
16 fire safety citations on file: 5 on March 26, 2026, 4 on December 19, 2024, 7 on October 12, 2023.
Every fire safety citation16 citations
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 26, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 26, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 26, 2026 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · March 26, 2026 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 26, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 19, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · October 12, 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 · October 12, 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 · October 12, 2023 · Corrected (the home has a date of correction)
- D
Provide large enough exits.
K 231 · October 12, 2023 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 12, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 12, 2023 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · October 12, 2023 · Corrected (the home has a date of correction)