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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
0E
0F
Potential for minimal harm
0A
1B
0C
November 18, 2025Standard inspection, Complaint inspection · 7 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, review of clinical records, review of facility policy/procedures and interviews for 3 of 4 sampled residents (Resident #39, #68, and #76) reviewed for dining, the facility failed to ensure the residents dined in a dignified manner.
- 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 review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #66) reviewed for advance directives, the facility failed to ensure there was a physician's order indicating the resident's wishes related to cardiopulmonary code status, hospitalization, and intravenous fluids. Resident #66's diagnoses included asthma with acute exacerbation, dementia, and anemia. The quarterly MDS assessment dated [DATE] identified Resident #66 was cognitively intact and required moderate assistance with toileting hygiene, dressing, and minimal assistance with personal hygiene and bed mobility. [...]
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of the clinical record, review of facility policy, and interviews for 1 of 5 sampled residents reviewed for abuse (Resident #85), the facility failed to ensure the resident was free from misappropriation of property when staff members accepted monetary gifts from a resident against facility policy.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one of two sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure a registered nurse assessed the resident after a fall and failed to monitor the resident condition after a fall.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, review of the clinical record, review of facility policy/procedures and interviews for 1 of 3 sampled residents (Resident #2) reviewed for medication administration, the facility failed to ensure medication was prepared in accordance with professional standards.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of clinical records, review of facility policy, review of facility documentation, and interviews for one of five sampled residents (Resident #12) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident on admission.
- B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record reviews, review of facility documentation, and interviews for 3 sampled residents (Resident #74, #78 and #80) reviewed for hospitalization and discharge, the facility failed to provide the required notification of transfer and discharge to the state Ombudsman's office.
January 12, 2024Standard inspection, Complaint inspection · 7 citations
- 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 review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for respiratory care, the facility failed to notify the physician/APRN that a prescribed respiratory treatment was unavailable, and for 1 of 2 resident's (Resident #177) reviewed for notification of change, the facility failed to notify the resident representative when there was a change in the residents condition and new orders were obtained for a chest x ray and antibiotics.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #177) reviewed for discharge, the facility failed to ensure medication sent home with the resident upon discharge, was prescribed to the resident.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #11) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on scheduled shower days.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #52) reviewed for accidents, the facility failed to conduct neurological vital signs, according to facility policy, after the resident had an unwitnessed fall.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #4) reviewed for limited range of motion, the facility failed to follow the physician order in the treatment of a hand contracture.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #14 and 52) reviewed for accidents, the facility failed to follow the physician's orders related to transfers and ambulation.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for respiratory care, the facility failed to provide necessary respiratory medications for a newly admitted resident for 5 days.
September 21, 2021Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of facility policy and interview the facility failed to follow infection control guidelines related to glucometer (blood sugar measuring device) sanitizing.
Fire safety inspections
10 fire safety citations on file: 4 on November 18, 2025, 5 on January 12, 2024, 1 on September 21, 2021.
Every fire safety citation10 citations
- D
Provide properly protected cooking facilities.
K 324 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · January 12, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 12, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · September 21, 2021 · Corrected (the home has a date of correction)