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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
1F
Potential for minimal harm
0A
0B
0C
April 2, 2025Standard inspection · 0 citations
May 10, 2024Standard inspection · 3 citations
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview the facility failed to follow an Antibiotic Stewardship program. This failure has the potential to affect all 41 residents who currently reside in the facility. Findings Include: CMS form 671 signed by V1, Administrator, on 05/08/24 documents there are 41 residents living in the facility. On 5/8/24 at 10:30 AM V3 (Licensed Practical Nurse/Infection Preventionist) stated that the facility utilizes the McGreer Criteria which are written definitions of what constitutes an infection. [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview the facility failed to ensure a prophylactic antibiotic was monitored for effectiveness and not prescribed in excessive duration for one of five residents (R8) reviewed for unnecessary medications in the sample of 18.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene during resident cares for two of 12 residents (R36 and R40) reviewed for infection control in a sample of 18.
May 4, 2023Standard inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to change oxygen tubing and humidification bottle as ordered for one resident (R4) out of one resident reviewed for oxygen administration in a sample of 15.
- 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 observation, interview and record review the facility failed to provide informed consent for an antipsychotic medication, failed to identify target behaviors and failed to identify an appropriate supporting diagnosis for one resident (R22) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 15.
Fire safety inspections
14 fire safety citations on file: 4 on April 2, 2025, 3 on May 10, 2024, 7 on May 4, 2023.
Every fire safety citation14 citations
- F
Establish roles under a Waiver declared by secretary.
E 26 · April 2, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 2, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 2, 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 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 10, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 4, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 4, 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 · May 4, 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 · May 4, 2023 · Corrected (the home has a date of correction)
- E
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
K 913 · May 4, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · May 4, 2023 · Corrected (the home has a date of correction)