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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
5E
1F
Potential for minimal harm
0A
0B
4C
May 15, 2025Standard inspection · 10 citations
- E
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 interview and record review, the facility failed to ensure interdisciplinary team (IDT) participation and care plan meetings for 5 of 5 residents reviewed, specifically Resident #3, 6, 18, 16, and 11.
- E
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, review of menus, and policy review, the facility failed to ensure the menu was developed for a mechanical soft diet, affecting 5 of 21 current residents, to include sampled Residents #15, #6, #17, #177, and #16.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to adhere to infection control practices by failing to update the water management plan to include the appropriate team, failing to maintain linens in clean condition, failing to keep the laundry sorting area clean, and failing to disinfect blood pressure monitoring equipment after use.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview, the facility failed to ensure a functional wheelchair for 1 of 1 sampled resident, Resident #17, whose wheelchair lock had been broken since admission to the facility.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to assess for and or assist to formulate advance directives upon admission for 1 of 1 sampled resident, Resident #17.
- 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, record review, and policy review, the facility failed to implement timely interventions and or adaptive equipment to ensure eating independence for 1 of 4 sampled residents, Resident #17, reviewed for Activities of Daily Living (ADLs).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper nail care 1 of 4 sampled residents, Resident #6, reviewed for Activities of Daily Living (ADLs).
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide physician ordered liquid consistencies for 1 of 1 sampled resident, Resident #17, who was downgraded to nectar liquids.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interviews, policy review, and record review the facility failed to ensure recommended diet upgrade was followed and communicated to staff for 1 of 3 sampled residents, Resident #16.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews, the facility failed to ensure daily staffing information included the number of nursing staff for 4 of 4 days and that it was posted for the correct date on 1 of 4 days.
February 1, 2024Standard inspection · 6 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 affecting all residents who eat their meals in the facility.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure competent nursing staff as evidenced by the failure to: 1) Document the antibiotic stop-date for 1 of 1 sampled resident receiving antibiotic therapy (Resident #130); 2) Document medication administration for 5 of 5 sampled residents chosen for unnecessary medications (Residents # 12, #4, #13, #81, and #26); and follow blood pressure parameters for 1 of 5 sampled residents (Resident #4); 3) Ensure resident was educated to the proper technique of inhaler administration for 1 of 6 observed for medication administration (Resident #81); 4) Accurately document the number of medications administered as evidenced by inconsistencies between the January 2024 MAR and the actual number of medications administered for 1 of 6 sample residents for medication administration (Resident #17); [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a working television (TV) for 1 of 1 sampled resident who voiced a complaint (Resident #80).
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services as per resident choice for 1 of 2 sampled residents observed who received blood sugar level checks (Resident #10).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and policy review, the medication error rate was 7.14 percent. Two medication errors were identified while observing a total of 28 opportunities, affecting 2 of 7 residents observed (Residents #8 and #4).
- C
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on record review and interviews, the facility failed to ensure the Binding Arbitration Agreements complied with all regulatory requirements. This affected all residents who signed the facility's current arbitration agreement.
October 6, 2022Standard inspection · 6 citations
- E
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 interview the facility failed to ensure care plan meeting were being held in a timely manner and the required IDT (Interdisciplinary Team) members participated in the care planning process for 7 of 13 reviewed, (Resident #2, #3, #11, #12, #16, #20, and #173).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure on going activities for Resident#16 for 1 of 2 reviewed for activities.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, policy review and interview the facility failed to follow their policy related to weights for Resident #16 who had a significant weight loss, for 1 of 1 resident sampled for nutrition.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure 1 of 2 sampled nurses (Staff C, a Licensed Practical Nurse/LPN) was competent in following policy and procedures during the medication pass observations for 2 of 4 sampled residents (Residents #19 and #9). Staff C failed to document the administration of medications at the time the medications were actually given to Residents #19 and #9, thus failing to ensure the safe delivery of medications. Staff C also failed to administer the medications for Resident #19 at the scheduled time.
- C
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to develop baseline care plan summaries with the resident's initial goals, summary of medications, dietary instructions, and services and treatments, to 4 of 4 sampled residents, to ensure coordination of care with the resident and or resident representative (Resident #74, #173, #12, and #20). This failure had the potential to affect all newly admitted residents as managerial staff reported they did not document their Meet and Greet meetings, where they review the baseline care plans with the residents and families.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interview, the facility failed to ensure garbage and refuse were disposed of properly.
Fire safety inspections
17 fire safety citations on file: 6 on May 15, 2025, 6 on February 1, 2024, 5 on October 6, 2022.
Every fire safety citation17 citations
- F
Conduct testing and exercise requirements.
E 39 · May 15, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 15, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 15, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · May 15, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 1, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 1, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · February 1, 2024 · 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 1, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 1, 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 · February 1, 2024 · Corrected (the home has a date of correction)
- 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 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 6, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 6, 2022 · Corrected (the home has a date of correction)