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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
5D
2E
0F
Potential for minimal harm
0A
0B
0C
May 8, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteOn 05/08/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to protect residents with exit seeking behaviors. Resident #1 had exit seeking behaviors and exited the facility on 04/28/25. Resident #1 was located by security to be lying on the ground on the sidewalk outside of one of the exit doors from household #3. Resident #1's care plan did not address elopement. Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for wandering and elopement. The administrator identified 70 residents resided in the facility and Resident #1 was the only resident able to walk independently.
October 3, 2024Standard inspection · 2 citations
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain an informed consent prior to the installation of bed rails for one (#39) of one sampled resident reviewed for bed rails. The DON identified 14 residents had bed rails in the facility.
- D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation and interview, the facility failed to ensure snacks were offered to all residents in the facility for one of one snack observation. The DON identified 65 residents received meal services from the kitchen.
August 11, 2023Standard inspection · 3 citations
- 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 record review and interview, the facility failed to ensure a comprehensive care plan included a bed alarm for one (#69) of 17 sampled residents reviewed for comprehensive care plans. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 67 residents resided in the facility.
- D
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 observation, record review. and interview, the facility failed to ensure a resident's care plan was updated to reflect their current diet order for one (#54) of 17 sampled residents reviewed for revised care plans. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 67 residents resided in the facility.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure controlled medications were signed off on the MAR for one (#57) of six sampled residents reviewed for accurate records. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 67 residents resided in the facility.
July 26, 2022Standard inspection · 3 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, observation and interview the facility failed to ensure a Resident was provided pain medication for complaints of pain during the provision of wound care for one (#28) of three sampled Residents who were reviewed for pain management. Resident #28 stated they were in pain before and during incontinent care and wound care, when asked by LPN #1 and CNA #1. Resident #28 moaned and cried out Oh and Ow several times during incontinent care and wound care and stated, Someone is hurting me. The staff did not stop the incontinent or wound care, asssess and intervene for Resident #28's pain. Resident #28 recieved pain medicaiton one hour and 29 minutes after the first complaint of pain. The Resident Census and Conditions of Residents, documented eight Residents had a pressure ulcer. The DON identified 15 Residents who were provided wound care.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observation , and interview the facility failed to ensure physician's orders were followed for treatments related to edema and pressure ulcer prevention for one (#28) of two sampled residents who had pressure ulcers and one sampled resident who had edema. The Resident Census and Conditions of Residents documented eight residents had pressure ulcers. The DON identified seven residents who had edema.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation and interview, it was determined the facility failed to have system in place to ensure employees consistently screened for COVID-19 symptoms prior to starting their shift for five of five employees reviewed for COVID-19 screening. The Resident Census and Conditions of Residents documented 63 residents resided in the facility.
Fire safety inspections
6 fire safety citations on file: 3 on October 3, 2024, 3 on July 26, 2022.
Every fire safety citation6 citations
- 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 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 3, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 3, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 26, 2022 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 26, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 26, 2022 · Corrected (the home has a date of correction)