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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
1E
0F
Potential for minimal harm
0A
1B
0C
April 22, 2026Standard inspection · 2 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review, review of Long Term Care Ombudsman notifications of transfers and discharges, and staff interview, the facility failed to notify the Ombudsman of a transfer to the hospital for 2 of 3 residents sampled (Residents #58 and #7). The facility reported a census of 57 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, clinical record review and staff interview, the facility failed to ensure staff administered medicated inhalers per physician order for 2 of 3 sampled residents (Residents #24 and #7). The facility reported a census of 57 residents.
April 9, 2025Standard inspection · 2 citations
- 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 clinical record review, facility policy review, and staff interview, the facility failed to accurately obtain and implement advanced directives per resident and family directives upon admission for 1 of 1 residents (Resident #202) reviewed. The facility reported a census of 51 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure 2 foot pedals used when a staff pushed a resident in their wheelchair for 1 of 7 (Resident #17) reviewed for accidents. The facility reported a census of 51 residents.
November 14, 2024Standard inspection · 5 citations
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on Centers for Medicare and Medicaid Services (CMS) Certification and Survey Provider Enhanced Reports Reporting (CASPER) system, review of the facility Quality Assurance Performance Improvement (QAPI) Policy, and staff interview the facility failed to ensure effective measures had been taken to correct deficiencies that continue. The facility reported a census of 50 residents.
- 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 observation, clinical record review, policy review, resident, guardian, and staff interviews, the facility failed to notify the legal guardian of laboratory refusals and resident change in condition for 1 of 5 resident reviewed for medication use (Resident #7). The facility reported a census of 50 residents.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation, clinical record review, and staff interviews the facility failed to ensure resubmission of the a Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for 1 of 1 residents reviewed (Resident #21). The facility reported a census of 50 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, resident and staff interviews, the facility failed to complete post dialysis assessments for 1 of 1 residents sampled (Resident #12). The facility identified a census of 50 residents.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, resident and staff interviews, the facility failed to complete the Minimum Data Set to accurately reflect the tobacco status for 2 of 2 residents reviewed for smoking (Resident #49 and #18). The facility identified a census of 50 residents.
July 3, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote2. The MDS assessment dated [DATE] revealed Resident #53 BIMS score 12 out of 15 indicating a moderate cognitive impairment. The MDS revealed the resident dependent with chair/bed to chair transfers and used a wheelchair. The MDS revealed a diagnosis of hemiplegia, unspecified affecting left dominant side. The Care Plan revealed a focus area dated 4/17/24 for ADL (Activities of Daily Living) self-care performance deficit for left-sided hemiplegia. The interventions dated 5/14/24 revealed transfers with an assist of 2 with a mechanical lift and use of a green sling. The EHR (Electronic Health Record) revealed the following Physician Orders: a. Start date 7/2/24- monitor left forearm skin tear and bruising until healed every shift for skin tear and bruising b. Start date 7/2/24- left forearm: [...]
September 7, 2023Complaint inspection · 7 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented resident used indwelling catheter and received an antibiotic for 6 out of 7 days. The MDS revealed diagnoses of amputation; complete traumatic amputation at the level between knee and ankle, right lower leg, sequela; completed traumatic amputation at level between knee and ankle, left lower leg, sequela; neurogenic bladder; Paraplegia; Depression (other than bipolar); pressure ulcer of other site, Stage 4. The Baseline Care Plan dated 8/1/23 documented resident took antibiotics and did not check the box for nurse monitoring. The Care Plan with revision date 8/16/23 revealed a focus area of required catheterization of a suprapubic catheter due to a diagnosis of neurogenic bladder. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy the facility failed to ensure the dignity of one of three reviewed (Residents #37). The facility reported a census of 54 residents.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, clinical record review, staff and resident interviews and facility policy review the facility failed to prevent the misappropriation of resident money for one out of one residents reviewed (Resident #10). The facility reported a census of 54 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation clinical record review, staff and resident interviews and facility policy review the facility failed to initiate the investigation immediately after the resident report the missing money to staff (Resident #10). The facility reported a census of 54 residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, clinical record review, staff and resident interview and facility policy review the facility failed to complete a through investigation for an allegation from a resident that reported missing money for one of of one residents reviewed (Resident 10). The facility reported a census of 54 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the resident received only his prescribed medication and the resident received his antibiotic as prescribed for 1 of 11 residents reviewed for standards of practice for medication administration (Resident #18). The facility reported a census of 54.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to time limit the use of a new as needed (PRN) anti-anxiety medication to 14 days and failed to implement interventions to try prior to administration of the medication for 1 of 5 resident reviewed for psychotropic medication use (Resident #49). The facility identified a census of 54 residents.
Fire safety inspections
8 fire safety citations on file: 4 on April 22, 2026, 1 on April 9, 2025, 3 on November 14, 2024.
Every fire safety citation8 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 9, 2025 · 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 · November 14, 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 · November 14, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 14, 2024 · Corrected (the home has a date of correction)