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
13D
5E
2F
Potential for minimal harm
0A
0B
2C
May 1, 2025Standard inspection · 4 citations
- 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 record review and interview, the facility failed to ensure residents and or responsible parties received room change notifications in writing. This affected three residents (Resident #4, Resident #17, Resident #18) of six residents reviewed for room change notifications. The census was 56.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a physician's order for oxygen was in place for Resident #37. This affected one (Resident #37) of one resident reviewed for oxygen use. The facility had a total of nine residents who were on oxygen. The facility census was 56.
- C
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on review of the personnel files and interview with staff the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 56 residents.
- C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment was accurately completed. This had the potential to affect all 56 residents residing in the facility.
August 8, 2022Standard inspection · 7 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed substantiate self-reported incident (SRI) tracking number (#)223300 dated 06/27/22 after resident personal checks written to the facility were compromised. This affected six (Residents #5, #19, #22, #27, #29, and #44) of six residents reviewed for misappropriation. The facility census was 44.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 19 residents (Residents #35, #46, #244, #245, #246, #247, #248, #249, #250, #251, #252, #253, #254, #255, #256, #257, #258, #259 and #260). The facility census was 44.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, record review, interview, drug manufacture review, and facility policy review the facility failed to ensure drugs in the medication storage room refrigerator were stored at the proper temperatures and dated when opened. This affected eight (Resident's #1, #4, #10, #23, #36, #40, #41, #194) and had the potential to affect all 44 residents residing in the facility.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on interview and record review, the facility failed to ensure closed resident accounts were refunded within 30 days. This affected two (Resident's #145 and #261) of two residents reviewed for closed accounts. The facility census was 44.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #9's annual assessment was submitted within 14 days after completion. This affected one (Resident #9) of one resident reviewed for assessments. The facility census was 44.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #28's hearing aid was replaced in a timely manner. This affected one (Resident #28) of one resident reviewed for hearing. The facility census was 44.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review the facility failed to provide documented evidence indwelling urinary catheter care was provided to Resident #22. This affected one (Resident #22) of two (Resident's #5 and #22) the facility identified as having an indwelling urinary catheter. The facility census was 44.
August 29, 2019Standard inspection · 11 citations
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of personnel files, review of the facility's criminal background check log, review of the abuse prohibition policy and interview, the facility failed to implement the abuse policy to ensure all potential employees had criminal background checks and reference checks completed upon hire. This affected one (Licensed Nursing Home Administer) of eight personnel files reviewed. This had the potential to affect all 54 residents.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, Infection Control Log review and staff interview, the facility failed to administer eye drops to in a sanitary manner and failed to maintain a comprehensive Infection Control Log indicating the pathogens for residents who had urinary tract infections. This affected one resident (Resident #7) of seven observed for medication administration and five residents (Resident #32, Resident #152, Resident #17, Resident #31 and Resident #257) with urinary tract infections but had the potential to affected all 54 residents in the facility.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of resident council meeting minutes, review of resident grievance/concern logs and associated forms and interview, the facility failed to adequately address resident concerns regarding call light response times. This had the potential to affect all 54 residents.
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on review of the Beneficiary Notice worksheet, review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review forms, review of a Notice of Medicare Non-Coverage (NOMNC) form and interview, the facility failed to provide residents with the correct forms when their services were no longer covered under Medicare. This affected three (Resident #49, Resident #152 and Resident #153) of three residents reviewed for provision of beneficiary notices. The facility census was 54.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review and interview, the facility failed to complete comprehensive resident assessments a minimum of every 12 months. This affected two (Residents #1 and #10) of four residents reviewed for resident assessments. The facility census was 54.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on medical record review and interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments a minimum of every three months. This affected one (Resident #9) of four residents reviewed for MDS assessments.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on medical record review and interview, the facility failed to transmit a Minimum Data Set (MDS) assessment in a timely manner. This affected one (Resident #3) of four residents whose resident assessments were reviewed.
- 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 adequately care plan and monitor behavior for Resident #21. This affected one of one resident reviewed for behavior.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, the facility failed to implement a resident's bowel protocol. This affected one (Resident #23) of five residents whose records were reviewed for medication use.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, medical record review, policy review, and interview, the facility failed to administer nutritional formula through a feeding tube in a manner to prevent microbial growth. This affected one (Resident #10) of one resident reviewed for feeding tubes. The facility identified three residents receiving tube feedings.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, staff interview and Medscape website review, the facility failed to ensure Resident #4's laboratory results were addressed timely. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications.
Fire safety inspections
6 fire safety citations on file: 1 on May 1, 2025, 3 on August 8, 2022, 2 on August 29, 2019.
Every fire safety citation6 citations
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 8, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 8, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 8, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 29, 2019 · Corrected (the home has a date of correction)
- E
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · August 29, 2019 · Corrected (the home has a date of correction)