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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
2E
2F
Potential for minimal harm
0A
0B
0C
June 11, 2025Standard inspection, Complaint inspection · 4 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R23) of 5 sampled residents had documentation that indicated their legal representative was informed of the risks and benefits of prescribed psychotropic medication. R23 was prescribed lorazepam (antianxiety medication). The facility did not ensure an informed consent for medication was reviewed and completed with R23's legal Guardian.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R304) of 17 sampled residents were provided safe administration of drugs and biologicals. On 6/9/25, Surveyor observed an albuterol 90 base inhaler (albuterol inhaler) and artificial eye gel drops on R304's bedside table. R304 did not have an order for the eye drops or an order for either medication to be left at the bedside.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff followed enhanced barrier precautions (EBP) for 1 resident (R) (R34) of 5 sampled residents. R34 was on EBP due to colonization of a multidrug-resistant organism (MDRO) to prevent the spread of the organism/infection to other residents. On 6/10/25, Registered Nurse (RN)-D did not wear the appropriate personal protective equipment (PPE) while completing high-contact resident cares for R34.
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R28) of 2 residents reviewed for elopement. R28's care plan indicated R28 was at risk for wandering/elopement after an episode of confusion while outside on 10/7/24. A WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was placed on R28's left ankle. On 5/20/25 at 3:36 AM, the local police department notified the facility that R28 was found two and a half blocks from the facility. Staff were unaware R28 had left the facility. An assessment indicated R28 had no injuries. [...]
May 6, 2025Complaint inspection · 1 citation
- 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 staff and resident interview and record review, the facility did not provide appropriate catheter care and services for 1 resident (R) (R1) of 3 sampled residents. R1 had a history of kidney stones, took anticoagulant mediation, and had a Foley catheter. R1 had an order to flush the catheter with acetic acid. On 4/23/25, R1's catheter was flushed with vinegar. The facility did not update R1's physician timely when R1 experienced gross hematuria (a large amount of blood in the urine).
March 5, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R6) of 1 resident observed during the provision of cares. On 3/5/25, staff did not ensure enhanced barrier precautions (EBP) were followed during high-contact resident cares for R6.
November 8, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the spread of communicable disease and infection for 1 resident (R) (R6) of 6 sampled residents. R6 was on enhanced barrier precautions (EBP). During an observation of pericare on 11/7/24, Certified Nursing Assistant (CNA)-D reached inside CNA-D's gown with soiled gloves to retrieve a walkie talkie. In addition, CNA-D threw soiled linens on R6's floor and did not change gloves or complete hand hygiene appropriately.
May 15, 2024Standard inspection · 5 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 47 residents residing in the facility. Staff did not complete hand hygiene prior to handling clean dishes. Staff did not maintain cooling logs for leftover food.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview and record review, the facility did not ensure potential adverse reactions to high-risk medications were monitored for 4 residents (R) (R22, R46, R11, and R30) of 5 residents reviewed for unnecessary medications. Staff did not monitor R22, R46, and R11 for potential side effects or adverse reactions to antibiotic medication. Staff did not monitor R22, R46, and R30 for potential side effects or adverse reactions to anticonvulsant medication.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff performed hand hygiene before administering medication and providing assistance for 4 residents (R) (R30, R24, R2, and R43) of 6 residents observed during medication administration. Licensed Practical Nurse (LPN)-J did not consistently perform hand hygiene during medication administration and while providing assistance to residents.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview and record review, the facility did not implement its written policies and procedures to prohibit mistreatment, neglect and abuse of residents for 1 (Cook (CK)-F) of 8 staff reviewed during the caregiver background compliance check. CK-F was hired on 2/20/24. CK-F's Department of Justice (DOJ) document indicated CK-F was charged with a qualifying offense on 6/27/24. The facility did not have additional information from the Clerk of Courts regarding the disposition of the case and the facts of the incident.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R30) of 5 sampled residents met the Pre-admission Screening and Resident Review (PASRR) requirements. R30 had a positive updated PASRR Level I Screen, dated 4/10/24, that indicated R30 had mental illness. A Level II Screen was not completed when R30 was prescribed psychotropic medication.
April 19, 2023Standard inspection · 2 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner which had the potential to affect all 56 residents residing in the facility. Uncovered desserts and drinks were transported from the hallway into resident rooms and the dining room. The dishwasher rinse temperature was above the required threshold of 194 degrees Fahrenheit (F). Juice cartridges in the juice machine were undated. A juice machine, microwave, and can opener were not in clean condition. A box with twelve containers of Quaker Oats Oatmeal was stored on the floor in the dry storage room.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure care was provided in accordance with a physician order for 1 Resident (R) (R1) of 14 sampled residents. R1 had a physician's order for a daily dressing change to an open wound on the right knee.
Fire safety inspections
22 fire safety citations on file: 7 on June 11, 2025, 5 on May 15, 2024, 10 on April 19, 2023.
Every fire safety citation22 citations
- F
Provide a written emergency evacuation plan.
K 711 · June 11, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 11, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 11, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 11, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 11, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 11, 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 · June 11, 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, 2024 · Waiver
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 15, 2024 · Corrected (the home has a date of correction)
- E
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 · May 15, 2024 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · May 15, 2024 · Waiver
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 15, 2024 · Waiver
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 19, 2023 · Corrected (the home has a date of correction)
- E
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 · April 19, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 19, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 19, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 19, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 19, 2023 · 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 · April 19, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · April 19, 2023 · Corrected (the home has a date of correction)