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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
1E
0F
Potential for minimal harm
0A
0B
0C
February 12, 2026Standard inspection · 0 citations
August 16, 2024Standard inspection, Complaint inspection · 9 citations
- J
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a residents' right to formulate an advance directive were honored for one of four residents reviewed for advance directives out of 35 sampled residents (Resident (R) 85). R85 who was his own decision maker, requested and signed to be a full code status (life saving measures) upon admission to the facility; however, the facility inadvertently entered a Do Not Resuscitate (DNR) order which contradicted the resident's decision. Additionally, the facility allowed the resident's Power of Attorney (POA) to sign DNR documents instead of the resident signing his own code status forms. This failure placed the resident at risk for death in the event of a cardiac and/or respiratory failure. An Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in §483.10 F578: [...]
- J
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, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for four of 35 sampled residents (Resident (R) 85, R90, R59, and R117). Upon admission to the facility, R85 chose his code status to be a full code; however, the resident's Care Plan contradicted his code status by having conflicting information when his care plan indicated he was a full code and had a do not resuscitate (DNR) code status. This placed the resident at risk for death in the event of cardiac and/or respiratory failure episode. An Immediate Jeopardy was identified at on [DATE] and was determined to exist on [DATE] at §483.21(b)(1) F656-Develop/Implement Comprehensive Care Plan. The Administrator was notified on [DATE] at 3:57 PM of the Immediate Jeopardy. [...]
- 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, record review, interview, and review of the facility's policy, the facility failed to ensure all supplies in the medication room and crash carts were not expired for three out of the six medication rooms and three out of the six crash carts. This had the potential for the facility to use expired medications and supplies that could potentially not be effective.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to report an allegation of abuse within two hours of the allegation for one of seven residents reviewed for abuse (Resident (R) 88) out of 35 sampled residents. On 06/28/2024 R88 reported an allegation of sexual abuse to the facility; however, the facility failed to report the allegation to the State Survey Agency (SSA) within the required two-hour time frame. R88 reported the allegation to the facility staff on 07/04/2024 at approximately 9:00 AM; however, the Administrator did not report the allegation to the SSA until 12:41 PM, which was outside of the required two-hour reporting timeframe. This failure placed the investigation of the allegation made by the resident at risk of being compromised. (Cross reference F610 and F842)
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to thoroughly investigate allegations of abuse for two of seven residents reviewed for abuse (Resident (R) 88 and R103) out of 35 sampled residents. R88 made an allegation of abuse on 07/04/2024 at approximately 9:00 AM. A facility staff member reported R103 was a victim of verbal abuse. (Cross Reference F842)
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a resident from wandering into other resident rooms for one (Resident (R) 68) of one sampled resident reviewed for wandering out of a total sample of 35.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to monitor the tunnel catheter post dialysis for complications for one (Resident (R) 90) of one sampled resident reviewed for dialysis out of a sample of 35 residents. The deficient practice could lead to potential complications that could impact the quality of R90's hemodialysis.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for side effects of an anticoagulant (blood thinner) for one (Resident (R)59) of five residents reviewed for unnecessary drugs out of a total sample of 35 residents. The deficient practice could potentially result in unnoticed bleeding.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' medical records were complete, accurately documented, contained a record of residents' assessments, and staff documentation of medical and non-medical status including the care and services provided across all disciplines for one of seven residents reviewed for abuse (Resident (R) 88 out of 35 sampled residents).
May 17, 2019Standard inspection · 3 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 observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to implement the care plan for one (1) of forty-four (44) residents, Resident #62. Resident #62 had a urinary catheter with a care plan to keep the collection tube below the level of the resident's bladder; however, observation revealed the resident's urinary collection bag was on the bed with the resident at the same level of the bladder.
- D
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, it was determined the facility failed to ensure the resident environment was free from accident hazards on one (1) of six (6) neighborhoods, the [NAME] neighborhood. Observation revealed a laundry dryer available for resident use had a sharp, protruding plastic piece sticking out where the door handle should be.
- 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 observation, interview, record review, and facility policy review, it was determined the facility failed to provide one (1) of forty-four (44) residents, Resident #62, with services to prevent complications related to an indwelling urinary catheter. Observations revealed Resident #62's urinary collection bag touched the floor and was on the bed at the level of the resident's bladder.
Fire safety inspections
12 fire safety citations on file: 5 on February 12, 2026, 7 on August 16, 2024.
Every fire safety citation12 citations
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · February 12, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 12, 2026 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · February 12, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 12, 2026 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · February 12, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 16, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 16, 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 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · August 16, 2024 · Corrected (the home has a date of correction)