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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
4D
0E
0F
Potential for minimal harm
0A
0B
0C
July 30, 2026Standard inspection, Complaint inspection · 3 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 record reviews and interviews with staff and the Physician, the facility failed to notify the physician when a resident with dysphagia (difficulty swallowing) had a choking incident when she was being fed dinner by a facility staff member for 1 of 3 residents reviewed for notification (Resident #42).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 2 of 27 residents whose MDS assessments were reviewed (Resident #67 and Resident #28).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted to the facility with diagnoses including post-traumatic stress disorder (PTSD) and depression for 1 of 3 residents reviewed for PASRR (Resident #2).
April 17, 2025Standard inspection · 0 citations
February 16, 2024Standard inspection, Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, Nurse Practitioner, and staff interviews, the facility failed to provide care safely when Nursing Assistant (NA) #1 and NA #2 transferred a resident who was dependent on staff assistance and unable to bear weight from his bed to chair by holding the resident under his arms. Resident #62 sustained an acute displaced left humeral (long bone in the arm between shoulder and elbow) neck fracture requiring use of a sling, orthopedic follow up, and resulted in pain for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #62).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review, Nurse Practitioner, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the focused infection control and complaint investigation survey of 8/18/22. This was for one deficiency in the area of Accidents/Hazards (F689) that was recited on the current recertification and complaint investigation survey of 2/16/24. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program.
Fire safety inspections
12 fire safety citations on file: 6 on April 17, 2025, 4 on February 16, 2024, 2 on October 15, 2021.
Every fire safety citation12 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 17, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 16, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 16, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 16, 2024 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · February 16, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 15, 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 · October 15, 2021 · Corrected (the home has a date of correction)