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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
7E
0F
Potential for minimal harm
0A
0B
0C
December 12, 2025Standard inspection · 8 citations
- E
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 observation, resident interview, staff interview, and facility document review the facility staff failed to provide a safe, clean, comfortable environment for 1 of 3 units in the facilty.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on resident interview, staff interview, and clinical record review the facility staff failed to ensure an accurate minimum data set assessment for 4 of 35 residents, Resident #18, Resident #2, Resident #61, and Resident #69.
- 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 staff interview, clinical record review and facility document review the facility staff failed to develop/implement a person-centered comprehensive care plan for 4 of 35 residents, Resident #2, Resident #15, Resident #75, and Resident #13.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests and physical, mental, and psychosocial well-being for 4 of 35 sampled residents, Resident #2, Resident #15, Resident #75, and Resident #13.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review the facility staff failed to ensure the resident received the provider ordered amount of oxygen for 1 of 35 residents, Resident #61. Resident #61's Oxygen was observed to be set at 4 1/2 liters and 5 liters a minute. The provider order was for 2 liters a minute. Resident #61's clinical record included the diagnosis chronic obstructive pulmonary disease (COPD). Section C (cognitive patterns) of Resident #61's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/26/25 included a brief interview for mental status (BIMS) score of 7 out of a possible 15 points. Per the MDS manual a score of 7=severe impairment in cognitive skills for daily decision making. [...]
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to use appropriate alternatives prior to the installation of side bed rails for 1 of 35 residents, Resident #2.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 35 sampled residents was free of significant medication errors, Resident #2.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, resident interview, staff interview and facility document review the facility staff failed to ensure a safe and functional environment for 4 of 85 resident rooms.
June 30, 2023Standard inspection · 3 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to safeguard resident private information on 1 of 4 units, 2 front.
- 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 resident interview, clinical record review, and staff interview, the facility staff failed to review and revise the residents Comprehensive Care Plan (CCP) for 1 of 39 residents, Resident #145.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were two errors in 25 opportunities for a medication error rate of 8%. These errors effected Resident's #106 and #149.
June 10, 2021Standard inspection · 5 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wrote5. For Resident #28, the facility staff failed to implement facility policy regarding reporting and investigating a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Essential Primary Hypertension, Anxiety Disorder Unspecified, Blindness One Eye Low Vision Other Eye, Muscle Weakness Generalized, and Difficulty in Walking. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wrote5. For Resident #28, the facility staff failed to report a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Essential Primary Hypertension, Anxiety Disorder Unspecified, Blindness One Eye Low Vision Other Eye, Muscle Weakness Generalized, and Difficulty in Walking. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interview, clinical record review, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to investigate alleged incidents of abuse for 4 of 30 residents, Residents #72, #131, #28 and #53.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and the review of documents, it was determined the facility staff failed ensure treatment and/or care was provided for a skin tear for one (1) of 30 sampled residents (Resident #47).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review the facility document review the facility staff failed to ensure a complete and accurate clinical record for 2 of 30 residents, Residents #142 and #92.
Fire safety inspections
22 fire safety citations on file: 1 on December 12, 2025, 10 on June 30, 2023, 11 on June 10, 2021.
Every fire safety citation22 citations
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 12, 2025 · Corrected (the home has a date of correction)
- F
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 · June 30, 2023 · Waiver
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 30, 2023 · Waiver
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 30, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 30, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 30, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 30, 2023 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · June 30, 2023 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 10, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 10, 2021 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 10, 2021 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 10, 2021 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 10, 2021 · 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 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 10, 2021 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 10, 2021 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 10, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 10, 2021 · Corrected (the home has a date of correction)