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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
15D
2E
0F
Potential for minimal harm
0A
2B
0C
July 25, 2025Complaint inspection · 1 citation
- 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for falls, the facility failed to ensure the resident had a comprehensive individualized fall care plan with interventions when identified as a high risk for falls.
February 10, 2025Standard inspection · 11 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on a tour of the Dietary Department, interviews and facility documentation, the facility failed to ensure foods were at appropriate temperatures for palatability.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interviews, review of the clinical record, and facility policy for 1 of 2 residents (Resident #343) reviewed for transmission-based precautions, the facility failed to notify the social worker, physician, and psychiatrist after a suicidal ideation statement was made, per the facility policy.
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 3 residents, (Resident #35), reviewed for abuse, the facility failed to ensure a resident exposed to a communicable illness was free to exit their room when wearing appropriate Personal Protective Equipment (PPE).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 3 residents, (Resident #10), reviewed for abuse, the facility failed to ensure that an injury of unknown source was reported to the state agency.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 3 residents, (Resident #10), reviewed for abuse the facility failed to ensure a complete investigation and summary were completed for a resident with an injury of unknown source.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews, review of the clinical records and facility policy for 1 of 2 residents (Resident #343) reviewed for transmission-based precautions, the facility failed to ensure the baseline care plan included statements/behaviors of homicidal ideation that were made prior to admission.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #53) reviewed for accidents, the facility failed to ensure floor mats were in place per the physician's order.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on interviews, review of the clinical records and facility policy for 1 of 2 residents (Resident #343) reviewed for transmission-based precautions, the facility failed to provide appropriate treatment and services for a resident who displayed psychosocial behaviors.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #53) reviewed for unnecessary medications, the pharmacist failed to identify irregularities for a resident receiving an antipsychotic (psychotic disorder) medication.
- 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 clinical record reviews, staff interviews, and facility policies for 2 of 5 residents (Resident #1 and Resident #53) reviewed for unnecessary medications, the facility failed to monitor behaviors for residents receiving psychotropic (drugs that affect the brain and nervous system) medications and for Resident #53, the facility failed to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment (test for abnormal movement) for a resident receiving an antipsychotic (psychotic disorder) medication.
- B
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews for 2 of 6 common areas, the facility failed to maintain a clean environment for two large vents on the North and East units.
December 3, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, review of facility documentation and policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who required staff assistance of one (1) when ambulating, the facility failed to utilize a gait belt when ambulating Resident #1 resulting in a fall and left lower leg fractures.
January 31, 2023Standard inspection · 5 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents for (Resident # 11) reviewed for abuse, the facility failed to report an allegation of staff to resident physical mistreatment to the overseeing state agency within required two hours after the suspected time of the abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents, resident (Resident # 11) reviewed for abuse, the facility failed to prevent further potential abuse following a report of staff to resident physical mistreatment.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #58 ) reviewed for positioning and mobility, the facility failed to complete a recommended Occupational Therapy (OT) or Physical Therapy (PT) evaluation after a quarterly therapy screen.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, facility documentation review, facility policy review, and interviews for two of four sanitizing solutions in the kitchen, the facility failed to maintain the sanitizing solutions at sanitary levels.
- B
Post nurse staffing information every day.
Inspectors wroteBased on review of the facility's posted staffing, observation and interviews, the facility failed to record an accurate resident census and number of direct care staff that was available for residents in the facility for and public view.
January 28, 2020Standard inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, facility documentation and interview for 1 of 3 residents (Resident #89) reviewed for accidents, the facility failed to appropriately utilize adaptive equipment which caused the hot liquid to spill resulting in a burn on the resident's leg, and for 1 nourishment kitchenette, the facility failed to ensure chemicals were stored in a locked cabinet and away from resident access.
- 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, review of facility documentation, facility policy, and interviews the facility failed to maintain sanitizing solutions at appropriate levels.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #4) reviewed for communication and sensory, the facility failed to provide timely follow when the resident lost his/her hearing aids.
Fire safety inspections
5 fire safety citations on file: 2 on February 10, 2025, 3 on January 31, 2023.
Every fire safety citation5 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 10, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · February 10, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 31, 2023 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · January 31, 2023 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · January 31, 2023 · Corrected (the home has a date of correction)