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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
4E
3F
Potential for minimal harm
0A
1B
0C
September 4, 2025Standard inspection · 6 citations
- F
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 facility policy review, medical record review, and interviews, the facility failed to ensure 3 residents (Resident #4, Resident #11, and Resident #17) were offered the opportunity to formulate an advanced directive upon admission to the facility of 3 residents reviewed for advanced directives.
- F
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review and interviews the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) for 3 residents (Resident #3, Resident #5, and Resident #33) of 3 residents reviewed for beneficiary notification.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on job description review, facility policy review, medical record review, and interview, the facility failed to provide effective administrative leadership and oversight to ensure the required documentation was maintained or obtained related to Notice of Medicare Non Coverage (NOMNC) for 3 residents (Resident #3, Resident #5, and Resident #33), failed to maintain or obtain the required documentation related to Advanced Beneficiary Notices (ABN) for 3 residents (Resident #3, Resident #5, and Resident #33), failed to offer assistance with the formulation of Advanced Directives for 3 residents (Resident #4, Resident #11, and Resident #17), and had not documented staff or residents received education on COVID-19 vaccination for 5 residents (Resident #7, Resident #11, Resident #19, Resident #24, and Resident #32), and had not offered the COVID-19 vaccine to the staff since 2022.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on facility policy review, job description review, Quality Assurance Performance Improvement (QAPI) meeting minutes review, medical record review, and interview, the facility's leadership and QAPI Committee failed to identify, address and initiate corrective action plans for quality deficiencies to ensure the residents attained or maintained their highest practicable physical, functional, mental, and psychosocial well-being when the residents were not offered the opportunity to formulate advanced directives upon admission, were not provided Advance Beneficiary Notices (ABN) or Notice of Medicare Non-Coverage (NOMNC) documentation upon discharge, and had not documented the staff or residents received education on the COVID-19 vaccine for 5 residents (Resident #7, Resident #11, Resident #19, Resident #24, and Resident #32), and had not offered the COVID-19 vaccine to the facility's [...]
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on medical record review , facility policy review, review of current Centers for Disease Control (CDC) recommendations and interviews the facility failed to document education was provided to residents and staff regarding COVID-19 vaccination, failed to document offering the COVID vaccine to residents and completing a declination form if the vaccine was declined, and failed to offer staff COVID-19 vaccines affecting all staff and 5 of 5 (Resident #7, #11, #19, #24 and #32) sampled residents reviewed.
- 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 facility policy review, medical record review, observation, and interviews, the facility failed to obtain a physician's order for the use of an indwelling urinary catheter [a tube inserted into the bladder that drains urine] for 1 resident (Resident #12) of 4 residents reviewed for the use of an indwelling catheter.
July 13, 2022Standard inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, Centers for Disease Control and Prevention (CDC) guidance, observation, and interview, the facility failed to properly prevent COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) by failing to implement universal use of eye protection as part of Personal Protective Equipment (PPE) during resident care interactions in a community with high COVID-19 transmission which had the potential to result in COVID-19 transmission to all 11 residents in the facility.
- E
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 that included person-centered interventions for 2 residents (Resident #8 and Resident #15) of 4 residents reviewed for comprehensive care plans.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to follow physician's orders for 1 resident (Resident #15) of 3 residents reviewed for insulin administration.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on Resident Assessment Instrument Manual 3.0 (RAI) record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 6 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) of 16 residents reviewed for MDS assessments.
May 8, 2019Standard inspection · 1 citation
- 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 medical record review, and interview the facility failed to monitor behaviors and side effects for psychotropic medications for 1 resident (#116) of 5 residents reviewed for unnecessary medications.
Fire safety inspections
10 fire safety citations on file: 8 on September 4, 2025, 1 on July 13, 2022, 1 on May 8, 2019.
Every fire safety citation10 citations
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Establish staff and initial training requirements.
E 37 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Meet the requirements of an integrated health system.
E 42 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 4, 2025 · 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 · July 13, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 8, 2019 · Corrected (the home has a date of correction)