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
0G
0H
0I
Potential for more than minimal harm
17D
0E
0F
Potential for minimal harm
0A
0B
1C
September 22, 2025Standard inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review and interviews, it was determined that the facility staff failed to treat resident with dignity and care for resident's Activities of Daily Living (ADLs) /hygiene in a manner that promotes maintenance or enhancement of resident's quality of life. This was evident for 1 (Resident #69) out of 3 residents reviewed resident's dignity and ADLs/hygiene care during an annual survey.
- D
Provide activities to meet all resident's needs.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, record review and facility policy review, it was determined that the facility failed to ensure meaningful activities to meet the needs/interests of the residents and to provide consistent resident centered/personalized activities for the dependent, confined residents in a manner that promotes maintenance or enhancement of residents' quality of life. This was evident for 2 (Resident #35 and Resident #69) out of 3 residents reviewed for ongoing resident centered activities program during an annual survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that the environment of 1) resident's rooms and 2) a resident's shower chair was maintained in a manner that minimized the potential for the spread of infection. This was evident for 3 of 4 areas reviewed during the annual recertification survey.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interviews with staff, it was determined that the facility failed to ensure that the call system cord was accessible in the resident's bathroom. This was evident for 1 (Resident #57) of 1 resident's bathroom observed during the annual survey.
- D
Put firmly secured handrails on each side of hallways.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and staff interview, it was determined that the facility staff failed to ensure that handrails were on all walls in resident areas including both resident's rooms and all resident common areas. This was evident for 2 of 2 nursing units and all common areas observed during the survey. This deficient practice had the potential to affect all residents, staff, and visitors on the units.
October 18, 2023Standard inspection, Complaint inspection · 3 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, medical record review and interview it was determined the facility failed to follow physician's orders and the resident's care plan for the administration of oxygen. This was evident for 1 (#56) of 1 resident reviewed for the administration of oxygen.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to ensure documentation of residents' Pneumococcal vaccination status in their medical records. This was evident for 1 (Resident #369) of 5 residents reviewed who were eligible for Pneumococcal vaccines during the survey.
- C
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 medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#52, #65, #218) of 3 residents reviewed for hospitalization.
February 7, 2019Standard inspection · 10 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 and staff interview it was determined that facility staff failed to ensure that residents' dignity was provided in 1) Providing personal grooming care, and 2) Long call light response times. This was evident for 2 out of 32 residents (R#63 and R#93) reviewed during the survey process. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on the medical record and staff interviews, the facility staff failed to provide a Care Plan for Resident #69's continuing care, to the hospital where the resident was being sent. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process.
- 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 medical record and staff interviews, the facility staff failed to provide necessary written notices for Resident #69, or the resident's responsible party, of a transfer out of the facility. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process.
- 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 the medical record and staff interviews, the facility staff failed to provide required written notice for Resident #69, or the resident's responsible party, of the bed hold policy during a transfer out of the facility. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical records review and interview with staff it was determined that the facility staff failed to ensure that the information used to complete the Minimum Data Set (MDS) significant change in condition assessment was accurate and complete when a diagnosis for hospice care was not coded into the MDS assessment. This was evident for 1 of 32 residents (Resident #1) reviewed in the annual survey.
- 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 medical record review it was determined the facility staff failed to develop a care plan for residents with impaired skin integrity. This was evident for 2 out of 4 resident's reviewed with non-pressure related skin conditions. Resident #8 and Resident #37 were affected by the deficient practice.
- 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 facility staff interview, family interview, and observation of residents' records, the facility failed to individualize the care plan for Resident # 72. This was evident for 1 out of 32 residents investigated for care plan revision.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review and interviews of facility staff it was determined the facility failed to ensure that staff were transferring residents from bed to chair/chair to bed in accordance with the residents' care plans. This was evident for 2 of 7 sampled residents reviewed for accidents. Resident #1 and Resident #5 were affected by the deficient practice.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interviews it was determined that required staff posting information was not in a prominent place readily accessible to residents and visitors. This was evident during the entire survey process.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interviews with family and staff; and record review, the facility failed to individualize the care plan for 1 out of 32 residents investigated for individualized care plans.
Fire safety inspections
20 fire safety citations on file: 12 on September 22, 2025, 6 on October 18, 2023, 2 on February 7, 2019.
Every fire safety citation20 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 22, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 22, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 22, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · September 22, 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 22, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · September 22, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 22, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · September 22, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · September 22, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · September 22, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 22, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 22, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 18, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 18, 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 18, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · October 18, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 18, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 18, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 7, 2019 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · February 7, 2019 · Corrected (the home has a date of correction)