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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
3E
0F
Potential for minimal harm
0A
0B
0C
August 12, 2025Standard inspection, Complaint inspection · 9 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record reviews, resident, staff, resident representative, and Nurse Practitioner (NP) interviews, the facility failed to protect the resident's right to be free from abuse for 4 of 30 residents reviewed for abuse (Resident #32, Resident #59, Resident #86, and Resident #125). On 05/09/25, Resident #32 was heard yelling for help when Resident #154 entered Resident #32's room and grabbed her by the neck and pinned her against the wall. Resident #32 was noted to be swatting at Resident #154 to free herself. Resident #154 sustained scratches to left ear. On 04/20/25, Resident #154 balled up his fist and hit Resident #86 in the mouth. Resident #86 sustained a cut to her upper lip with bleeding. On 04/17/25, Resident #32 was heard yelling for help when Resident #154 entered Resident #32's room and grabbed her arm and pulled it. [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to identify abuse and ensure staff implemented facility's abuse policy and procedures for reporting abuse. This occurred when the facility failed to report allegations of resident-to-resident abuse to the State Survey Agency within the specified time frames. The facility also failed to notify the county Adult Protective Services (APS) of allegations of abuse. This deficient practice affected 4 of 30 residents reviewed for abuse (Resident #32, Resident #59, Resident #86, and Resident #125).
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and staff interviews, the facility failed to complete a thorough investigation after allegations of resident-to-resident abuse occurred. This deficient practice affected 4 of 30 residents reviewed for abuse (Resident #32, Resident #59, Resident #86, and Resident #125).
- E
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 observations, record reviews, and Nurse Practitioner and staff interviews, the facility failed to accurately assess 3 of 3 severely cognitively impaired residents for bilateral half side rails on their beds (Resident #2, Resident #64, and Resident #77).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to maintain a resident's dignity when incontinence care was not provided as needed for 1 of 3 residents reviewed for dignity (Resident #139).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on record reviews, staff, and family interviews, the facility failed to protect private health information for residents when they provided Resident #153's medical records and a list of resident names, room numbers, medical record numbers, and allergies to Resident #43's Representative at a medical appointment. This deficient practice affected 1 of 2 residents reviewed for privacy (Resident #153).
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review, and Hospital Case Manager, Resident's Representative, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric (psych) evaluation. The resident remained in the hospital despite being medically cleared to return to the nursing home after 5 days. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #154).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide incontinence care to a resident when needed and was alerted by a family member that Resident #139 had laid in a urine soaked brief, clothes, under pad and sheets for several hours. This deficient practice was for 1 of 3 residents reviewed for providing activities of daily living care (Resident #139).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, and resident, staff, pharmacy and Nurse Practitioner (NP) interviews, the facility failed to prevent a drug regimen free from unnecessary drugs for 1 of 17 residents reviewed for unnecessary medications. Resident #142 was administered a tuberculosis skin test using tubersol. Record Review indicated to only perform a screening as Resident #142 had an allergy to tubersol.
May 2, 2024Standard inspection · 3 citations
- D
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 record review, observation, resident, and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan in the areas of urinary catheter use and opioid (pain medication) use (Resident #89). This deficient practice was for 1 of 5 residents whose comprehensive care plans were reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy and procedure when Nurse #1 failed to sanitize her hands after doffing gloves used to clean stool smears from a resident's rectum and before donning clean gloves to apply treatment to the resident's rectum and then failed to doff her gloves, sanitize her hands and don clean gloves before refastening the resident's brief for 1 of 3 residents (Resident #21) reviewed for incontinence care.
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 14 rooms on the memory care unit reviewed for privacy (room [ROOM NUMBER]).
January 12, 2023Standard inspection · 1 citation
- 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 review, and interviews with staff, responsible party and Nurse Practitioner the facility failed to notify the physician when a resident (Resident #142) experienced a second change in condition when the resident's wrist started to swell following an unwitnessed fall. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #142).
Fire safety inspections
16 fire safety citations on file: 3 on May 2, 2024, 13 on January 12, 2023.
Every fire safety citation16 citations
- 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 · May 2, 2024 · 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 · May 2, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 2, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 12, 2023 · 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 · January 12, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 12, 2023 · 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 · January 12, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 12, 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 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · January 12, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 12, 2023 · Corrected (the home has a date of correction)