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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
5E
1F
Potential for minimal harm
0A
2B
1C
April 6, 2026Standard inspection · 3 citations
- 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, interview, and record review, the facility failed to monitor range of motion (ROM) of left knee flexion contracture and implement the care plan to maintain ROM to reduce the risk of worsening the contracture for one Resident (#13), out of a sample of 13 residents.
- D
Ensure the physician properly assigns and delegates tasks to a qualified dietitian (or other qualified nutrition professional); or to a qualified therapist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the physician signed therapeutic diet orders for total parenteral nutrition (TPN- a method of delivering complete nutrition intravenously to patients who cannot use their digestive system), written by a registered dietitian (RD) for one Resident, (#10), out of a total sample of 13 residents.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interview, the facility failed to ensure trash, garbage, and refuse were disposed of and properly contained within a receptacle constructed with a tight-fitting lid.
January 28, 2025Standard inspection · 5 citations
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interviews, the facility failed to ensure for one Resident (#15), out of a total sample of 21 residents, that the Resident's legal guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated) was informed of a change in skin condition by the physician or other practitioner or professional, informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he/she preferred. [...]
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 14 of 14 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for three Residents (#85, #15, and #23), out of a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #85, staff implemented a taper and discontinuation of a Nicotine patch (smoking cessation treatment) recommended by the consultant pharmacist and agreed upon by the Resident's physician; 2. For Resident #15, the consultant wound physician did not perform treatments including invasive surgical procedures, cauterization, ultrasound therapy and substitute skin grafts to the Resident's wounds without obtaining informed consent to do so from the Resident's legal guardian; and 3. [...]
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of five nurses observed made two errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted two Residents (#22 and #64).
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the call light was accessible and within reach for one Resident (#37), out of a total of 21 sampled residents. Specifically, the facility failed to ensure the call light switch above Resident #37's bed had a string attached to it to enable the Resident to independently call for assistance.
October 31, 2023Standard inspection · 6 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on document review, policy review, and interviews, the facility failed to maintain an infection prevention and control program with a complete and accurate system of surveillance to identify any trends of actual or potential infections within the facility using their predetermined infection definition criteria.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, policy review, grievance review, and review of Resident Council Minutes, the facility failed to ensure residents' grievances were brought forward and the grievance process was implemented, and concerns were resolved in a timely manner. Specifically, the facility failed: 1. For Resident #2, to implement the grievance process for lost laundry; and 2. To address and promptly resolve several grievances regarding lost laundry brought forward during the September 2023 Resident Council Meeting.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure it was free from a medication error rate of greater than 5% when 1 out of 3 nurses observed made 2 errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted one Resident (#56), out of three residents observed.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, policy review, and interview, the facility failed to ensure all drugs and biologicals were secured in locked compartments with only authorized personnel having access.
- B
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), the facility failed to provide written notice to the State agency when a change in the facility's Administrator and a change in Director of Nursing (DON) occurred.
- B
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on document review, policy review, and interview, the facility failed to ensure their arbitration agreement specifically provides for the selection of a venue that is convenient to both parties.
Fire safety inspections
9 fire safety citations on file: 1 on April 6, 2026, 3 on January 28, 2025, 5 on October 31, 2023.
Every fire safety citation9 citations
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 6, 2026 · Corrected (the home has a date of correction)
- F
Ensure medical gas and vacuum systems have documented maintenance programs.
K 907 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 28, 2025 · 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 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · October 31, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 31, 2023 · Corrected (the home has a date of correction)
- E
List the names and contact information of those in the facility.
E 30 · October 31, 2023 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 31, 2023 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · October 31, 2023 · Corrected (the home has a date of correction)