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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
2E
1F
Potential for minimal harm
0A
0B
0C
April 17, 2025Standard inspection · 3 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Residents #67, #189 and #196 were provided with showers as scheduled. This finding affected three residents (#67, #189 and #196) of five residents reviewed for showers. The facility census was 85.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations, interviews and review of the facility policy, the facility failed to ensure oxygen tubing was changed and dated and oxygen was set to the ordered liter flow per minute. This affected five residents (#1, #5, #8, #61, and #65) out of eight residents reviewed for oxygen. The facility census was 85.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff knocked on Resident #21's room door and/or asked permission to enter the resident's room prior to entering. This affected one resident (#21) of one resident reviewed for privacy. The facility census was 85.
January 24, 2023Standard inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, observations and interviews the facility failed to provide a dignified existence for all residents. This affected one (Resident #36) of 10 residents observed for activities and staff interaction. The census was 66. Findings Include: Review of medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included unspecified dementia, history of falls, and anxiety disorder. Resident #36 was receiving hospice services. Review of the plan of care dated 08/17/21 revealed Resident #36 was at risk for falls due to balance problems, history of falls and weakness. Review of the plan of care dated 12/09/22 revealed Resident #36 had a self-care deficit and required assistance by staff for activities of daily living (ADL). Review of the 01/16/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #36 revealed she had severe cognitive impairment. [...]
December 18, 2019Standard inspection · 11 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of three unstageable pressure ulcers for Resident #55. Actual Harm occurred on 12/05/19 when Resident #55, who was bedfast and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown tissue] and/or eschar [tan brown or black tissue] in the wound bed) pressure ulcers to the right heel, left heel and coccyx. This affected one Resident (#55) of two residents reviewed for pressure ulcers. The facility identified three current residents with pressure ulcers.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on record review, observation and interviews, the facility did not ensure foods were served at palatable temperatures. This had the potential to affect all residents in the facility except for one Resident (#35) who did receive food by mouth. The facility census was 77.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to provide written notification of room changes to Resident #29 prior to conducting the room changes. This affected one Resident (#29) of one resident reviewed for room changes and had the potential to affect all 77 residents residing in the facility.
- D
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, interview and policy review, the facility failed to ensure Resident #10 and Resident #29 were free from physical abuse. This affected two residents (Residents #10 and #29) of three residents (Residents #10, #29 and #131) reviewed for abuse and neglect. The facility census was 77.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, interview and policy review, the facility failed to implement the policy and procedure for reporting alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview and policy review, the facility failed to report alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interview and policy review, the facility failed to thoroughly investigate a physical abuse incident involving Resident #10 and Resident #29. This affected two Residents (#10 and #29) of three residents reviewed for abuse and neglect. The facility census was 77.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) recommendations were incorporated into Resident #53's plan of care. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place for Resident #53. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #52 had a current discharge plan of care and failed to have documented evidence of care plan meetings. This affected one (Resident #52) of two (Residents #52 and #79) reviewed for discharge. The facility census was 77.
- 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 Resident #52 was wearing a wander/elopement alarm per physician's order. This affected one (Resident #52) of two (Residents #52 and #8) reviewed for wandering/elopement. The facility census was 77.
Fire safety inspections
8 fire safety citations on file: 4 on April 17, 2025, 2 on January 24, 2023, 2 on December 18, 2019.
Every fire safety citation8 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 17, 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 · April 17, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · April 17, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 24, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 24, 2023 · Corrected (the home has a date of correction)
- F
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 18, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 18, 2019 · Corrected (the home has a date of correction)