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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
2E
1F
Potential for minimal harm
0A
0B
2C
February 27, 2025Standard inspection · 5 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on resident interview, staff interview, and observation the facility failed to maintain a comfortable environment related to resident room temperatures. This affected one resident (Resident #288) of nine residents reviewed for room temperature.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, manufacture guideline review and interview, the facility failed to ensure Resident #284's pin care was completed as ordered and Resident #181's left hand rash was provided appropriate skin treatments. This finding affected one (Resident #284) of three residents reviewed for wounds and one (Resident #181) of one for general skin conditions.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review and interview, the facility failed to arrange transportation for Resident #53's appointment resulting in Resident #53's eye surgery being canceled. This affected one resident (#53) of one reviewed for vision. The facility census was 75.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure dentist recommendations for oral surgery services were implemented for one (Resident #21) of two residents reviewed for dental services.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interviews, the facility failed to ensure the laundry room and washers were maintained in clean working order. This had the potential to affect all 75 residents residing in the facility.
December 20, 2023Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure all residents on the 400 hall were monitored and provided timely assistance with incontinence care throughout the night. This finding affected six residents (Residents #1, #18, #33, #37, #51, #63) of 39 residents who reside on the 400 hall.
November 13, 2023Complaint inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, the facility failed to maintain proper infection control practices/procedures to prevent the spread of infection including COVID-19. This had the potential to affect all 75 residents residing in the facility.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents discharged from skilled services were provided appropriate notification in writing of services ending. This affected one resident (#76) of three residents reviewed for beneficiary notification. The facility census was 75.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer Resident #71 according to the plan of care. This affected one resident (#71) of one resident observed for transfer assistance. The facility identified 17 residents (#4, #5, #12, #17, #18, #19, #23, #26, #28, #32, #44, #46, #63, #65, #67, #69, and #71) who required mechanical transfer assistance. The facility census was 75.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided to Residents #46 and #71. This affected two residents (#46 and #71) of two residents observed for incontinence care. The facility census was 75.
September 1, 2022Standard inspection · 4 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 the Patient Handbook and interview, the facility failed to provide a dignified dining experience when disposable dishware and flatware were used to serve meals. This affected two (Residents #27 and #68) of 17 residents interviewed regarding dignity. The census was 65.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #3 was assisted with meals timely and offered supplements or alternate food items when she refused her meal. This finding affected one (Resident #3) of two residents reviewed for activities of daily living (ADL).
- C
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of schedules and interview, the facility failed to ensure the director of nursing did not work as a charge nurse when the average daily census was greater than 60. This had the potential to affect all 65 residents.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, review of schedules, and interview, the facility failed to ensure posted nurse staffing information was accurate. This had the potential to affect all 65 residents.
September 12, 2019Standard inspection · 2 citations
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interview, the facility failed to ensure state tested nursing assistants (STNAs) received annual education regarding dementia and care of the cognitively impaired. This had the potential to affect 61 residents (Residents #1, #3, #4, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #22, #23, #24, #25, #27, #29, #30, #32, #33, #35, #36, #37, #38, #41, #42, #44, #48, #50, #51, #52, #54, #55, #56, #58, #59, #60, #61, #63, #64, #66, #67, #68, #69, #70, #71, #76, #77, #78, #81, #83, #89, #90, #291, #292, #293, #294, #295 and #296) of 84 residents who were assessed to be cognitively impaired or who had diagnoses of dementia or Alzheimer's disease.
- 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, medical record review, policy review, and interview, the facility failed to ensure timely physician notification of signs of a urinary tract infection for Resident #38. This affected one of 23 residents whose medical records were reviewed.
Fire safety inspections
10 fire safety citations on file: 3 on February 27, 2025, 2 on September 1, 2022, 5 on September 12, 2019.
Every fire safety citation10 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 1, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 1, 2022 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 12, 2019 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · September 12, 2019 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 12, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 12, 2019 · Corrected (the home has a date of correction)
- D
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 · September 12, 2019 · Corrected (the home has a date of correction)