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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
2E
0F
Potential for minimal harm
0A
0B
1C
June 5, 2025Standard inspection · 3 citations
- 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 interview and record review, it was determined that the facility failed to determine if a resident's request for rehabilitation services was necessary or appropriate for 1 of 1 resident reviewed for Specialized Rehabilitative or Restorative Services in a final sample of 28 residents (Resident identifier is #57).
- 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, it was determined that the facility failed to ensure that the resident's medical records were complete and accurate for 3 of 28 residents in a final sample of 28 residents. (Resident identifier are #44, #46, and #68.)
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that residents are offered the COVID-19 and are educated regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations (Resident Identifiers are #46 and #124).
March 14, 2024Standard inspection · 9 citations
- 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, interview, and record review, it was determined that the facility failed to ensure controlled medications were stored in a separately locked, permanently affixed storage compartment in 2 of 2 medication rooms observed, and that the facility failed to ensure that medications were appropriately disposed of in 2 of 3 medication administrations observed.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review it was determined that the facility failed to make a Level II Pre-admission Screening and Resident Review (PASARR) referral for a resident with a newly evident mental disorder for 1 of 3 residents reviewed for PASARR in a final survey sample of 27 residents (Resident Identifier is #26).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) screening was done for 1 of 3 residents reviewed for PASARR in a final sample of 27 residents (Resident Identifier is #111).
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to ensure adequate staffing to provide assistance with breakfast on 1 of 3 units observed (South Unit).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained for 2 of 2 narcotic books reviewed. Findings Include: East Unit Medication Cart Observation on 3/12/24 at approximately 9:30 a.m. of the East Unit Narcotic/Controlled Substance Log - Shift Count revealed missing staff signatures for the following dates: [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that residents on antipsychotic medications were monitored for side effects for 2 of 5 residents reviewed for unnecessary medications in a final sample of 27 residents (Resident Identifiers are #12 and #42).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to facility established infection prevention procedures for 1 of 4 residents reviewed with catheters and for transmission based precautions for 2 of 6 residents reviewed for infection control in a final sample of 27 residents (Resident Identifiers are #75, #172, and #174).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure a resident was offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza vaccination for 2 of 5 residents reviewed for vaccinations (Resident identifiers are #29 and #107).
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and record review, it was determined that the facility failed to post the daily nurse staffing data for 1 of 2 days observed (3/13/24). Interview on 3/14/24 at 7:37 a.m. with Staff G (Staff Development Coordinator) revealed that the daily nurse staffing data was posted in 2 places in the facility, on the bulletin board in the hallway leading into the [NAME] Unit and in the window in the entrance way of the facility. Observation on 3/14/24 at 7:40 a.m. of the bulletin board in the hallway leading into the [NAME] Unit revealed the facility nurse staffing data dated 3/12/24. Interview on 3/14/24 at 7:41 a.m. with Staff G confirmed the above. Observation on 3/14/24 at 7:42 a.m. of the entrance way to the facility revealed the daily nurse staffing data was taped to the window. Observation further revealed that the daily nurse staffing data was dated 3/11/24. [...]
February 17, 2023Standard inspection · 2 citations
- 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, interview and record review, it was determined that the facility failed to ensure that medications were labeled with an open date or use by date for medications found in 2 out of 3 medication carts and 1 out of 2 medication rooms observed; and failed to ensure medications were secured on 1 out of 3 nursing units observed (Resident identifiers are #15, #19, #26, #31, #82 and #87).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to follow manufacturer's instructions for medication administration for 1 out of 1 inhaled medications observed and failed to follow physician's orders for 1 out of 1 Gastrostomy tube (G tube) medication administration observed (Resident identifiers are #15 and #21). Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #15 Observation on 2/15/23 at approximately 11:45 a.m. [...]
Fire safety inspections
12 fire safety citations on file: 6 on June 5, 2025, 5 on March 14, 2024, 1 on February 17, 2023.
Every fire safety citation12 citations
- E
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
K 913 · June 5, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 5, 2025 · 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 5, 2025 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · June 5, 2025 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 5, 2025 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · June 5, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 14, 2024 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 14, 2024 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · March 14, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 14, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 14, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · February 17, 2023 · Corrected (the home has a date of correction)