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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
2E
0F
Potential for minimal harm
0A
1B
0C
April 30, 2026Standard inspection · 3 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an environment that was free from restraints imposed for purposes of discipline or convenience for two Residents (#66 and #9) out of a total sample of 19 residents. Specifically, the facility failed to:1. For Resident #66, the facility failed to identify and assess the use of an abduction pillow (a soft, firm foam pillow that is placed between the thighs and strapped onto the patient's legs while they are in a resting position) that was fastened with a Velcro strap wrapped around the Resident's legs as a potential restraint. 2. For Resident #9, the facility failed to assess the use of bolsters to both sides of the Resident's bed as a physical restraint when staff applied the bolsters to restrict the Resident's attempts to get out of bed. Findings Include: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice relative to the cleaning and storage of oxygen and respiratory equipment for one Resident (#33) out of a total sample of 19 residents. Specifically, for Resident #33, the facility failed to ensure that the Resident's oxygen concentrator (device used to deliver supplemental oxygen) filter was cleaned as required, and that the Resident's nasal cannula (medical device that delivers supplemental oxygen directly into the nostrils), nebulizer (a medical device that converts liquid medicine into a mist) mask and a non-invasive mechanical ventilator mask were appropriately stored when not in use, to mitigate the risk of contamination, spread of infection, impaired oxygen delivery and equipment malfunction.
- B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure the required documentation was provided to the receiving facility/health care provider for two Resident's (#4 and #10) of four applicable residents reviewed for hospitalizations, out of a total sample of 19 residents, to ensure a safe and effective transition of care. Specifically for Resident #4, the facility failed to provide information that included but not limited to the following: provider contact information, resident representative contact information, advanced directives (legal document that outlines an individual's wishes regarding future major medical decisions), and any special care instructions and precautions for ongoing care. [...]
February 7, 2025Standard inspection · 2 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, and interview, the facility failed to ensure a homelike environment for resident dining on three units (South Unit, North Unit and East Unit) of three units observed. Specifically, the facility failed to: -provide meals and/or meal assistance timely to Residents (#23, #59, #3, and #11), who were seated with other residents during meals. -remove resident meals off the meal trays before serving meals during communal dining.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#37) out of a total sample of 19 residents, was free from physical restraints. Specifically, the facility failed to ensure that Resident #37 was assessed for the use of a rectangular cushion, which was positioned on his/her right side of the bed under the fitted sheet, and being used to prevent the Resident from putting his/her feet over the side of the bed.
November 20, 2024Complaint inspection · 2 citations
- J
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was a functional quadriplegic (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), was essentially non-verbal, unable to participate in his/her care, and was totally dependent on staff to meet all of his/her care needs, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality, when on [DATE], after Nurse #1 was notified by Nurse Aide (NA #1) that during care Resident #1 began to slide out of bed and she (NA #1) lowered him/her to the floor, although Nurse #1 said she assessed Resident #1 for the potential for injury prior to moving him/her off the floor, Nurse #1 was unable to say what she did to assess him/her. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a functional quadriplegic (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), who was totally dependent on staff to meet all of his/her needs, the facility failed ensure he/she was provided with an adequate level of staff supervision during the provision of care to maintain his/safety to prevent an incident/accident resulting in serious injury. On [DATE], Nurse Aide (NA) #1, prepared Resident #1, who was in bed, for incontinent care. NA #1 raised the bed from the low position, repositioned Resident #1 on his/her right side, and left Resident #1 unattended while she went into the bathroom to fill the wash basin with water. [...]
December 22, 2023Standard inspection · 2 citations
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, record review, and interview, the facility failed to complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process, for one Resident (#61) out of a total sample of 18 residents. Specifically, the facility staff failed to assess Resident #61's cognitive status and mood through the required resident interview process when the Resident had adequate hearing, clear speech, and sometimes made him/herself understood and sometimes understood others.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that one Resident (#79) who required assistance with bed mobility, out of a total sample of 18 residents, received mobility assistance while in bed.
Fire safety inspections
10 fire safety citations on file: 5 on April 30, 2026, 3 on February 7, 2025, 2 on December 22, 2023.
Every fire safety citation10 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 30, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 30, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 30, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 30, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 30, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 7, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 7, 2025 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · February 7, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · December 22, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 22, 2023 · Corrected (the home has a date of correction)