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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
1E
1F
Potential for minimal harm
0A
0B
0C
February 27, 2025Standard inspection · 7 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for 4 of 8 residents reviewed for EBP, as evidenced by not utilizing personal protective equipment (PPE) while performing physical therapy evaluation for Resident #41 and while providing assistance with feeding for Resident #388, failed to develop a care plan for EBP for a resident on Dialysis (Resident #477), and failed to implement EBP for a resident with an indwelling urinary catheter (Resident #58); and the facility failed to provide laundry services in a sanitary manner.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with dining in a manner to maintain dignity for 2 of 32 residents in the final sample (Resident #387 and #388).
- 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 observation, interview, and record review, the facility failed to care plan dentures for 1 of 1 resident reviewed for dental (Resident #34); Failed to implement a care plan for dialysis for 1 of 3 residents reviewed for dialysis (Resident #387); and Failed to implement interventions for behaviors during dining for 1 of 30 residents who eat lunch in the [NAME] Dining Room (Resident #66).
- 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 ensure a resident's wheel chair was maintained in a manner to prevent a skin tear to 1 of 5 residents reviewed for accidents (Resident #388).
- 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 identify a resident with a urinary catheter, and failed to obtain urology consult as ordered for 1 of 2 residents reviewed for urinary catheter (Resident #58).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow physician orders to not take blood pressure (BP) on dialysis access extremity for 3 of 5 residents (Resident #128, Resident #442, and Resident #387); and failed to have an order for dialysis for Resident #387.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the professional standards for controlled substances reconciliation for 2 of 5 sampled residents (Resident #443 and Resident #107).
February 15, 2024Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure documentation was available to show whether dialysis treatment was started timely; the facility failed to ensure bathing preference was documented; and the facility failed to ensure physician order for self-administration of peritoneal dialysis was timely recorded, for 1 of 3 sampled residents (Resident #1).
October 20, 2023Standard inspection, Complaint inspection · 5 citations
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care and services for assistance with eating for 2 (Resident #381 and #383) of 10 sampled residents reviewed for nutrition.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food, in accordance with professional standards for food service safety.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, observation, and record review, the facility failed to appropriately respond to a grievance related to billing for 1 of 1 resident, Resident #328.
- 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 report an allegation of neglect related to a fall with major injury (fractured hip) for 1 of 5 residents reviewed for accidents (Resident #179).
- D
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 provide supervision and monitoring to prevent a fall with fracture for 1 of 5 residents reviewed for accidents (Resident #179).
June 23, 2022Standard inspection · 8 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in a sanitary manner.
- 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 facility policy, observation, interview, and record review, the facility failed to protect the residents' personal belongings (clothing) from being lost or damaged. This failure affected 4 0f 7 residents reviewed for personal belongings (Residents #65, #17, #12, and #100).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities to meet the needs of a cognitively impaired resident for 1 of 4 residents reviewed for activities, Resident #61.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and facility policy the facility failed to properly assist a resident with Preoperative care for 1 of 1 resident reviewed for surgery (Resident #17).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on on observation, interview, and record review, the facility failed to perform tracheostomy (trach) care as ordered for 1 of 1 residents reviewed for trach care (Resident #107).
- 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 interview and record review, the facility failed to document the providers' response and/or rationale to decline the pharmacist's recommendations from the Medication Regimen Review (MMR), for 5 of 5 residents reviewed (Residents #31, #56, #58, #78 and #103). The facility also failed to develop and implement policies and procedures for the required monthly Medication Regimen Review conducted by their pharmacy.
- 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 interview and record review, the facility failed to monitor behaviors for psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #56).
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide meals according to residents' preferences for 1 of 4 residents reviewed for preferences, Resident #213.
Fire safety inspections
12 fire safety citations on file: 3 on February 27, 2025, 5 on October 20, 2023, 4 on June 23, 2022.
Every fire safety citation12 citations
- 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 · February 27, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 27, 2025 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 27, 2025 · Corrected (the home has a date of correction)
- D
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 · October 20, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 20, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 20, 2023 · Corrected (the home has a date of correction)
- D
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · October 20, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 20, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · June 23, 2022 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 23, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 23, 2022 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · June 23, 2022 · Corrected (the home has a date of correction)