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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
0E
0F
Potential for minimal harm
0A
0B
2C
May 7, 2025Standard inspection · 0 citations
January 9, 2025Complaint inspection · 1 citation
- 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 and interviews, the facility failed to ensure one of five residents (Resident (R) 1) reviewed received his pain medications as ordered creating the potential for increased discomfort.
February 8, 2024Standard inspection, Complaint inspection · 5 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Act for 1 (R11) of 1 residents reviewed for an allegation of a crime. R11 alleged facility staff forced her to take a shower and slammed her into the wall. R11's allegation of abuse was not reported timely to local law enforcement.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview & record review, the Facility did not ensure that 1 (R11) of 1 resident alleged incidents of physical abuse was thoroughly investigated, and the results of the investigation reported to the State Agency. R11 alleged staff forced her to take a shower and slammed her into the wall. The allegation was not thoroughly investigated as all staff involved were not interviewed, a physical assessment was not completed for injuries and other residents were not interviewed to see if they had similar concerns.
- 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, interview, and record review the Facility did not ensure that 1 (R134) of 1 Residents observed during medication pass with a gastronomy tube (G-tube) receives the appropriate treatment and services. R134's G-tube placement was not checked prior to administering medication via the G-tube.
- C
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 interview and record review, the facility did not ensure 1 (R11) of 1 sampled residents reviewed for a facility initiated discharge received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R11 was transferred to the hospital on [DATE] and 12/6/23. R11 and their representative was not provided a written notice of transfer.
- C
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review the facility did not ensure 1 (R11) of 1 residents reviewed for transfers or therapeutic leave received a written bed hold notice with the specific duration of the bed hold and policy information.
November 10, 2022Standard inspection · 5 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, observation and record review, the facility did not ensure that a resident with a deep tissue injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new deep tissue injuries from developing for 1 (R6) of 4 residents reviewed for pressure injuries. R6 developed a deep tissue injury and the facility did not implement an intervention put in place to promote healing.
- 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, interview, and record review the Facility did not ensure that 1 (R19) of 1 Residents observed during medication pass with a gastrostomy tube (G-tube) receives the appropriate treatment and services. R19's G-tube placement was not checked prior to administering medication via the G-tube.
- 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, record review and staff interview, the facility did not ensure residents received their medications. This was discovered with 2 (R3 and R16) of 4 residents that did not receive their medication as ordered. R3 and R4 had medications that were not administered to them as ordered.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and staff interview, the facility did not ensure psychotropic PRN (as needed) medication had indications for long term use. This was discovered with 2 (R3 and R2) of 4 residents reviewed for medication. R3 and R2 have received PRN Ativan beyond 14 days without indications for use to continue.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 1 (R18) of 5 residents observed. Two medication errors were observed out of thirty-one opportunities, for a total error rate of 6.45%. * R18 was administered Potassium Chloride Extended Release 10 Millequivalents (MEQ) extended release and Sublingual (under the tongue) Vitamin B12 1,000 milligrams (MG) crushed when they should not have been.
Fire safety inspections
14 fire safety citations on file: 3 on May 7, 2025, 9 on February 8, 2024, 2 on November 10, 2022.
Every fire safety citation14 citations
- F
Address patient/client population and determine types of services needed.
E 7 · May 7, 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 7, 2025 · Corrected (the home has a date of correction)
- D
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
K 925 · May 7, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
K 791 · February 8, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · February 8, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · February 8, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · February 8, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 8, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 8, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · February 8, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 10, 2022 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · November 10, 2022 · Waiver