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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
1H
0I
Potential for more than minimal harm
3D
3E
0F
Potential for minimal harm
0A
0B
0C
March 26, 2025Standard inspection · 3 citations
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to conduct a comprehensive assessment within 14 calendar days of admission for 2 (#104 and #205) of 13 sampled residents reviewed for comprehensive assessments. The administrator reported 51 residents resided in the facility.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurate for 2 (#37 and #46) of 2 sampled residents reviewed for anticoagulant therapy. The administrator reported 51 residents resided in the facility.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to follow physician orders related to insulin administration for 1 (#205) of 3 sampled residents reviewed for insulin administration. The DON reported 11 residents received insulin at the facility.
December 17, 2024Complaint inspection · 1 citation
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interview, the facility failed to ensure accurate wandering risk scale assessments were completed for two (#2 and #3) of three residents sampled for accurate wandering risk scale assessments. The DON identified eight residents were at risk for wandering and elopement.
August 22, 2024Complaint inspection · 2 citations
- H
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to provide an environment free from abuse for two (#7 and #8) of five sampled residents reviewed for resident-to-resident abuse. The Administrator identified 56 residents resided in the facility.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to ensure incident reports were created for documented incidents of inappropriate sexual behavior by one (#6) of five sampled residents reviewed for resident-to-resident abuse. The Administrator identified 56 residents resided in the facility.
December 1, 2023Standard inspection · 0 citations
January 5, 2023Standard inspection · 1 citation
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review, observation, and interview, the facility failed to obtain an appropriate rationale for a pharmacy recommended gradual dose reduction (GDR) for one (#4) of five residents whose records were reviewed for unnecessary medications. The Resident Census and Conditions of Residents, documented 38 residents resided in the facility and three residents were currently on antipsychotic medications.
Fire safety inspections
11 fire safety citations on file: 3 on March 26, 2025, 1 on December 1, 2023, 7 on January 5, 2023.
Every fire safety citation11 citations
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 1, 2023 · 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 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · January 5, 2023 · 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 · January 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 5, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 5, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 5, 2023 · Corrected (the home has a date of correction)