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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
6E
0F
Potential for minimal harm
0A
3B
1C
November 5, 2025Complaint inspection · 5 citations
- E
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review and interview, it was determined that the facility discharged a resident without an appropriate reason and failed to appropriately document the discharge of a resident. This was evident for 2 (#3 and #4) of 2 residents reviewed for an inappropriate discharge.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to issue a 30-day notice to residents when they planned to discharge them. This was evident for 2 (#3 and #4) of 2 residents reviewed for an inappropriate discharge.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to honor the wishes of the resident representative and allow the resident to stay at the facility while receiving hospice services. This was evident for 1 (#3) of 2 residents reviewed for discharge.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure that residents were free of chemical restraints and that PRN (as needed medications) psychotropics were limited to 14 days. This was evident for 1 (#4) of 2 residents reviewed for discharge.
- D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to inform residents and/or resident representatives about limitations in the care services that they provided. This was evident for 1 (#3) of 2 residents reviewed for discharge.
April 25, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure a thorough investigation was completed for allegations of abuse. This was found to be evident for 2 (Resident #189 & 180) out of 8 Residents investigated for abuse during the recertification and complaint survey.
February 25, 2021Standard inspection · 1 citation
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility's staff failed to promptly notify the ordering physician of laboratory results for 1 of 5 residents selected for review of Unnecessary Medications during the survey (Resident #122).
July 3, 2019Standard inspection · 3 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on surveyor observation and staff interviews, it was determined that the facility staff failed to store and serve food under sanitary conditions. This finding was evident in the facility's kitchen, dining room and passing of trays during Lunch observation.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview and record review, it was determined that facility staff failed to provide timely treatment and care. This was evident for 1 of 17 residents selected to review during the survey (#77).
- D
Keep all essential equipment working safely.
Inspectors wroteBased on surveyor observation and interview of facility staff, it was determined that the facility staff failed to inspect and maintain an electrically powered air mattress in safe operating condition. This finding was evident for 1 of 17 residents selected for review during the survey (#19).
May 14, 2018Standard inspection · 13 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on surveyor review of the clinical records, observation of staff practice and interview of facility staff, it was determined that the facility staff failed to provide care and treatment to meet an individual's need as ordered. This finding was evident for 4 of 16 residents selected for review during the survey process (#1, #73, #20, and #122).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on surveyor review of the clinical records and interview of facility staff and the consultant, it was determined that the facility staff failed to obtain a psychiatric nurse practitioner's progress notes timely. This finding was evident for 3 of 16 residents selected for review during the survey process (#12, #20, and #21).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on surveyor observation of staff practices, review of the clinical records and facility policy, and staff interviews, it was determined that the facility staff failed to use the correct transmission-based precautions for two residents with infections. This finding was evident for 2 of 16 residents selected for review during the survey process (#16 and #122).
- D
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 surveyor review of the clinical records, observation of resident and staff practice, and interview of a family member and the facility staff, it was determined that the facility staff failed to honor an individual's advance directives. This finding was evident for 2 of 3 residents selected for review of advance directives (#1, #22).
- 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 surveyor review of the clinical records, observation of resident and staff practice, and interview of a resident, a family member, facility staff and a consultant, it was determined that the facility staff failed to notify the responsible parties when a change of treatment was made. This finding was evident for 2 of 2 residents selected for review of notification of change (#12 and #20).
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on surveyor review of the clinical record and staff interviews, it was determined that the facility staff failed to address how resident preferences and physician orders related to CPR are communicated throughout the facility so that staff know immediately what action to take or not take when an emergency arises. This finding was evident for 1 of 1 resident selected for review of resident death (#22).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on surveyor review of the clinical records and interview of the facility staff, it was determined that the facility staff failed to ensure that an individual was free from excessive dosage of an antibiotic therapy for a prolonged period of time. This finding was evident for 1 of 7 residents selected for medication regimen review (#7).
- 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 surveyor observation, review of the clinical records and interview of a family member, facility staff and consultant, it was determined that the facility staff failed to ensure that an individual receive anti-depressants with appropriate clinical indications. This finding was evident for 2 of 7 residents selected for medication regimen review (#12 and #20).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on surveyor observation, review of the clinical record and staff interviews, it was determined that the facility staff failed to ensure that medication error rates were not 5 percent or lower. This finding was evident during the surveyors' observation of medication administration.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on surveyor observation of the building and interview of the facility staff, it was determined that the facility staff failed to maintain the garbage storage in a sanitary condition.
- B
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on surveyor review of the clinical record and interview of a resident and the facility staff, it was determined that the facility staff failed to develop a baseline care plan within 48 hours after admission (#73). This finding was evident for 1 of 5 residents who were admitted within 30 days of the survey.
- B
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 surveyor review of the clinical records, observation of resident and staff practice and interview of the facility staff, it was determined that the facility staff failed to develop a person-centered care plan for an individual. This finding was evident for 2 of 16 residents reviewed for comprehensive care plans (#11 and #122).
- B
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on surveyor review of the Quality Assurance (QA) minutes and interview of the administrator, it was determined that the QA committee failed to conduct ongoing monitoring of complaint and grievances. In addition, the QA committee failed to evaluate quality of care for an individual, who expired in the facility.
Fire safety inspections
7 fire safety citations on file: 2 on February 25, 2021, 1 on July 3, 2019, 4 on May 14, 2018.
Every fire safety citation7 citations
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · February 25, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 25, 2021 · Corrected (the home has a date of correction)
- B
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 3, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 14, 2018 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 14, 2018 · Corrected (the home has a date of correction)
- C
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 14, 2018 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · May 14, 2018 · Corrected (the home has a date of correction)