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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
5D
4E
0F
Potential for minimal harm
0A
0B
0C
February 27, 2025Complaint inspection · 2 citations
- G
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was served at a safe temperature to prevent a burn for 1 (#10) of 1 resident sampled for food related burns. The DON reported 51 residents received food from the facility kitchen.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's representative was issued a written discharge form for 1 (#152) of 1 sampled resident reviewed for involuntary discharge. The DON reported 52 residents resided in the facility.
August 30, 2024Complaint inspection · 1 citation
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to: a. ensure an allegation of abuse was fully investigated for one (#1); and b. prevent the potential for further abuse while an investigation was in progress for one (#1) of three sampled residents reviewed for abuse. The DON identified 47 resided in the facility.
July 17, 2024Complaint inspection · 2 citations
- E
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 interview, the facility failed to ensure the physician and/or the resident's representative were notified after a change in the resident's condition for one (#1) of three sampled residents reviewed for notification. The DON identified 42 residents resided in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to assess and monitor a resident after an unwitnessed fall for one (#1) of three sampled residents reviewed for accident hazards. The DON identified 42 residents resided in the facility.
December 28, 2023Standard inspection · 0 citations
September 14, 2022Standard inspection · 5 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to store and serve food to ensure food service safety. The Resident Census and Condition of Residents documented a census of 39 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain their infection control program. The facility failed to label and date a solution used to sanitize a glucometer for one (#25) of one sampled resident for finger stick blood sugar (FSBS) monitoring. The DON identified eight residents who required FSBS monitoring.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interviewed, the facility failed to ensure assessments accurately reflected the resident's use of oxygen for one (#4) of five residents reviewed for therapy. The Resident Census and Conditions of Residents, dated 09-12-22, documented 7 residents received respiratory treatment.
- 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, and interview, the facility failed to develop a comprehensive person-centered care plan for one (#4) of 13 residents whose care plans were reviewed. The Resident Census and Conditions of Residents, dated 09-12-22, documented 39 residents resided in the facility.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure: a. oxygen therapy was provided per professional standards of care for one (#4), and b. oxygen tubing and humidifier bottles were labeled and dated per professional standards of care for two (#4 and #34) of five residents reviewed for respiratory services. The Resident Census and Conditions of Residents, dated 09/12/22, documented, 7 residents received respiratory treatment.
Fire safety inspections
8 fire safety citations on file: 2 on February 27, 2025, 1 on December 28, 2023, 5 on September 14, 2022.
Every fire safety citation8 citations
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · December 28, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 14, 2022 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · September 14, 2022 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 14, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 14, 2022 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 14, 2022 · Corrected (the home has a date of correction)