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
1G
0H
0I
Potential for more than minimal harm
9D
0E
0F
Potential for minimal harm
0A
0B
0C
March 18, 2026Standard inspection · 2 citations
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on facility policy review, medical record review, observation, and interviews, the facility failed to administer a continuous enteral feeding (liquid nutrition provided by a tube inserted into the abdomen) as ordered by the physician for 1 resident (Resident #61) of 1 resident reviewed for continuous enteral feedings.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observations, and interviews, the facility failed to offer hand hygiene assistance to 4 residents (Residents #120, #122, #111, and #11) prior to meals of 4 residents observed during meal service on 1 of 5 units observed for meal tray distribution.
June 6, 2024Complaint inspection · 3 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wrote6. Review of the medical records and facility investigation documentation revealed a resident to resident altercation occurred between Resident #1 and Resident #6 on 4/27/2024. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, GAD, Chronic Obstructive Pulmonary Disease, and Gout. Review of quarterly MDS assessment dated [DATE], revealed Resident #1 scored a 5 on the BIMS assessment, which indicated severe cognitive impairment and required supervision with transfers and walking. The resident exhibited no negative moods or behaviors. [...]
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on facility policy review, medical record review, facility investigation review, personnel file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $600.00 was taken from 1 resident (Resident #34) of 8 sampled residents reviewed for misappropriation.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wrote2. The facility failed to report an allegation of resident to resident abuse that occurred between Resident #5 and #6 on 4/11/2024 to the State Survey Agency. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Generalized Anxiety Disorder (GAD), and Dementia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 2 on the BIMS assessment, which indicated severe cognitive impairment, and exhibited inattention. The resident had physical behavioral symptoms noted. Review of the Nurse's Progress Notes for Resident #5 dated 4/11/2024, revealed the Assistant Director of Nursing (ADON) documented at approximately 5:35 PM, Resident #5 was in dining area propelling self in wheelchair. [...]
August 24, 2022Standard inspection · 3 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to provide a clean and homelike environment in 1 resident's (Resident #64) room of 6 resident rooms observed.
- 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 facility policy review, medical record review, observation, and interview, the facility failed to develop a care plan addressing hospice care and management for 1 resident (Resident #48) of 20 residents reviewed for care plans.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were stored and administered safely for 1 resident (Resident #86) of 6 residents reviewed for medication administration, which had the potential to cause an accident, when a nurse left Resident #86's medication at the bedside unattended.
September 5, 2019Standard inspection · 2 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review and interview, the facility failed to make a referral to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) after newly identified serious mental disorders were diagnosed for 2 residents (#48, #86) of 8 residents reviewed for PASARR.
- 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 review of the facility policy, medical record review and interview, the facility failed to develop a comprehensive care plan for the diagnosis of Psychosis for 1 resident (#86) of 23 residents reviewed for care plans.
Fire safety inspections
8 fire safety citations on file: 1 on March 18, 2026, 5 on August 24, 2022, 2 on September 5, 2019.
Every fire safety citation8 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 18, 2026 · Corrected (the home has a date of correction)
- D
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 24, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 24, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 24, 2022 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 24, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 24, 2022 · Corrected (the home has a date of correction)
- D
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 · September 5, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 5, 2019 · Corrected (the home has a date of correction)