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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
2E
0F
Potential for minimal harm
0A
0B
0C
March 24, 2025Standard inspection · 2 citations
- D
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 record review and interview, the facility failed to provide a bed hold form for 2 of 4 residents reviewed for hospitalization. (Resident 1 & 35)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to ensure staff providing care for a resident in EBP (enhanced barrier precautions) wore appropriate PPE (Personal Protective Equipment) for 1of 2 residents reviewed for EBP. (Resident 10)
May 24, 2024Standard inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were stored appropriately and not expired and failed to ensure dishes and equipment was clean and in good working condition in 1 of 1 kitchens and 1 of 1 kitchenette observed. This deficient practice had the potential to affect 46 of 46 residents who receive meals from the kitchen and/or were served from the kitchenette.
March 31, 2023Standard inspection · 5 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure nail care was provided and ensure residents who required staff assistance for toileting were toileted timely to prevent further incontinence for 4 of 20 residents reviewed for ADL (Activities of Daily Living) care. (Resident 19,12, 24 and 29)
- 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 have a care plan for an open area for 1 of 3 residents reviewed for skin. (Resident7)
- 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, interview, and record review, the facility failed to revise care plans for changes in condition for 1 of 23 residents, whose care plans were reviewed. (Residents 44 )
- 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 failed to ensure a tube feeding solution was dated when hung, and a water flush bag was changed timely for 1 of 1 residents reviewed for tube feedings. (Resident 7)
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items in the freezer were sealed securely after opening, failed to ensure refrigerators were clean in 1 of 1 kitchens and 2 of 2 pantries. (main pantry and rehab pantry)
Fire safety inspections
44 fire safety citations on file: 13 on March 24, 2025, 14 on May 24, 2024, 17 on March 31, 2023.
Every fire safety citation44 citations
- F
Conduct testing and exercise requirements.
E 39 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 24, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 24, 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 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 24, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · March 24, 2025 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · March 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 24, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · May 24, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · May 24, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 24, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 24, 2024 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 24, 2024 · 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 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · May 24, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 24, 2024 · Corrected (the home has a date of correction)
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 24, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 31, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 31, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Conform to length requirements for dead end corridors.
K 251 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · March 31, 2023 · 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 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 31, 2023 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 31, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 31, 2023 · Corrected (the home has a date of correction)