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
0H
0I
Potential for more than minimal harm
2D
2E
1F
Potential for minimal harm
0A
2B
0C
June 26, 2025Standard inspection · 0 citations
June 6, 2024Standard inspection · 5 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on staff interview and record review the facility failed to submit accurate payroll data, regarding 24-hour licenses nurse coverage, for 9 of 9 days reviewed (10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, 12/31/23) of the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 1st quarter in fiscal year 2024.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews, the facility failed to discard expired food items, and label and date food available for resident use in 1 of 1 walk-in cooler and 1 of 4 reach-in coolers in the main kitchen, in 1 of 1 walk-in cooler and in 2 of 3 reach-in coolers in building 4 kitchen, and in 2 of 4 nourishment room refrigerators ([NAME] and blue bird pods' refrigerators) in the 3rd floor of building 4 where the nursing home residents resided. These practices had the potential to affect food and beverages served to the residents.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and resident and staff interviews the facility failed to follow their policy on pneumococcal vaccine and offer up to date pneumonia vaccines to 5 of 5 residents reviewed for immunization status (Resident #3, Resident #8, Resident #9, Resident #12, and Resident #123).
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) database (Resident #1) and failed to electronically transmit to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, a 5 day assessment within 14 days of the completion date (Resident #16) for 2 of 9 residents reviewed for resident assessment. Findings Included: a. Resident #1 was admitted on [DATE]. The discharge MDS assessment dated [DATE] was signed as completed on 3/8/24. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 6/5/24 did not indicate this assessment had been accepted. An interview was conducted on 6/6/24 at 10:22 AM with MDS Nurse #1. [...]
- B
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and staff interviews, the facility failed to review and revise the care plan in the area of falls for Resident # 2. This was for 1 of 9 residents reviewed for care plans.
February 9, 2023Standard inspection · 2 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBasedonrecordreviewandstaffinterviews thefacilityfailedtoprovidetheCentersforMedicare& MedicaidServices(CMS NoticeofMedicareNonCoverageLetter(NOMNC CMS10123 form for1 of3 sampledresidentsreviewedforbeneficiaryprotectionnotificationreview(Resident# 73).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 10/7/21 in order to achieve and sustain compliance. This was for recited deficiency on a recertification survey on 2/9/23. The deficiency was in the area of Medicaid/Medicare Coverage/Liability Notice. The continued failure during one federal survey of record showed a pattern of the facility's inability to sustain an effective quality assurance program.
Fire safety inspections
8 fire safety citations on file: 7 on June 6, 2024, 1 on October 7, 2021.
Every fire safety citation8 citations
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · October 7, 2021 · Corrected (the home has a date of correction)