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 19 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
4F
Potential for minimal harm
0A
0B
2C
March 6, 2025Standard inspection · 5 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 105.
- F
Have policies on smoking.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to develop and implement a smoking policy in accordance with federal, state and local laws and regulations in regards to smoking, smoking areas, and smoking safety for both smoking and non-smoking residents and staff. This had the potential to affect all residents. The facility census was 105.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, policy review, and review of Centers for Disease Control (CDC) recommendations, the facility failed to ensure appropriate hand hygiene was performed during meal tray distribution. This affected nine residents (#2, #13, #16, #38, #71, #73, #74, #90 and #101) out of nine residents observed for dining on the second floor. The facility census was 105.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure accurate weights were obtained for Resident #34. This affected one resident (#34) of one resident reviewed for nutrition. The facility census 105.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, staff interview, review of Centers for Disease Control (CDC) recommendation and review of manufacturers instructions the facility failed to ensure necessary respiratory equipment was utilized in a manner to provide maximum efficiency and benefit to the resident. The affected one (Resident #77) of two residents identified by the facility as requiring a bilevel positive airway pressure (bipap) machine while sleeping to address sleep apnea and other similar and related conditions. The facility census was 105.
November 27, 2023Complaint inspection · 1 citation
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure residents had access to call lights. This affected three (Residents #24, #104, and #20) of five residents reviewed for call lights. The facility census was 108.
December 5, 2022Standard inspection · 9 citations
- F
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 observation, staff interview, review of the temperature logs, and review of the facility policy review, the facility failed to ensure medications were stored with proper temperature controls. This affected two of four medication storage rooms reviewed for medication storage. This had the potential to affect all 80 residents residing in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wrote4. Review of Resident #292's medical record revealed the resident was admitted to the facility on [DATE]. Resident #292 died in the facility on 07/28/22. Diagnoses included chronic pancreatitis, chronic obstructive pulmonary disease (COPD), muscle weakness (generalized), unsteadiness on feet, history of falling, and presence of right artificial hip joint. Review of the significant change MDS assessment dated [DATE] revealed Resident #292 had moderate cognition impairment. Resident #292 required extensive assistance of one staff for bathing. Review of the hospice documentation revealed hospice provided baths to Resident #292 on 07/19/22, 07/21/22, and 07/26/22. Review of the bathing task sheet from 05/13/22 to 07/27/22 revealed Resident #292 did not get a bath or shower on 05/17/22, 05/20/22, 05/24/22, 05/27/22, 06/24/22, 06/28/22, 07/08/22, and 07/12/22. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, medical record review, review of the facility's policy, and staff interview, the facility failed to ensure the call lights were within reach and accessible for the residents. This affected two (Residents #37 and #242) of 26 residents observed for call lights within reach. The facility census was 80.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure cognition and mood were assessed on the comprehensive Minimum Data Set (MDS) assessments for three (#23, #41, and #70) of 20 residents reviewed for cognition and mood. The facility census was 80.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, medical record review, review of the facility policy, and staff interviews, the facility failed to provide a resident with an effective restorative ambulation program. This affected one (Resident #23) of four residents reviewed for restorative programs. The facility census was 80.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, medical record review, and staff interviews, the facility failed to ensure the resident's wound dressing changes were completed as physician ordered and were accurately documented in the resident's medical record. This affected for one (Resident #18) of two residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. The facility census was 80.
- 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, staff interview, medical record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one (Resident #83) of two residents reviewed for an indwelling urinary catheter. The facility identified eight residents with an indwelling or external catheter. The facility census was 80.
- C
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observations, review of the employee handbook, interview with residents at the resident council meeting, and staff interviews, the facility failed to ensure all staff were wearing name badges for residents to know whom was caring for them. This had the potential to affect all 80 residents residing in the facility.
- C
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on record review and staff interview, the facility failed to have a policy in place regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This had the potential to affect 80 residents residing in the facility who were able to receive food from outside sources.
August 12, 2019Standard inspection · 4 citations
- F
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on record review and interview, the facility failed to thoroughly check the Nurse Aide Registry prior to hiring a nurse aide. This affected one (STNA #100) of five personnel files reviewed. This had the potential to affect all 102 residents who resided at the facility.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was treated with dignity at all times. This affected one (Resident #39) of 23 sampled residents. The census was 104.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure call lights were within reach and accessible. This affected three (Residents #45, #79 and #98) of 104 residents reviewed for call light placement.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to ensure resident's laboratory orders were completed as ordered. This affected one of one resident (#60) reviewed for laboratory services. The facility census was 104 residents.
Fire safety inspections
27 fire safety citations on file: 15 on March 6, 2025, 3 on December 5, 2022, 9 on August 12, 2019.
Every fire safety citation27 citations
- F
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 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · March 6, 2025 · 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 · March 6, 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 · March 6, 2025 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 6, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · March 6, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · December 5, 2022 · Corrected (the home has a date of correction)
- E
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 · December 5, 2022 · Corrected (the home has a date of correction)
- E
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
K 227 · December 5, 2022 · Corrected (the home has a date of correction)
- E
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 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 12, 2019 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 12, 2019 · deficient, provider has