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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
1E
1F
Potential for minimal harm
0A
0B
0C
June 25, 2025Standard inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, facility documentation review, observation, and interview, the facility failed to maintain a clean and sanitary kitchen which had the potential to affect 92 of 92 residents.
- 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 facility policy review, medical record review, observation, and interview, the facility failed to revise the comprehensive care plan for 1 resident (Resident #94) of 20 residents reviewed for care plans.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, observation, and interviews, the facility failed to ensure medications were stored and secured properly for 1 resident (Resident #74) of 92 residents observed for accidents and hazards.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure oxygen therapy was administered at the physician prescribed rate for 1 resident (Resident #36) of 7 residents reviewed for oxygen therapy.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure the pharmacy provided an accurate physician prescribed medication for 1 resident (Resident #73) of 3 residents observed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed related to urinary catheter bag storage for 1 resident (Resident #94) of 10 residents reviewed for urinary catheters.
May 1, 2024Standard inspection, Complaint inspection · 7 citations
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on facility policies and procedures review, medical record review, and interviews the facility failed to permit 1 resident (Resident #350) to return to the facility after a hospitalization and failed to follow the facility's procedure for discharge for 1 resident (Resident #195) of 7 residents reviewed for Transfers and Discharge.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment timely for 1 resident (Resident #1) of 22 residents reviewed.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observations, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Residents #56) of 22 residents reviewed for MDS assessments.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on facility policy review, medical record review and interview, the facility failed to refer 2 (Residents #1 and #74) after the resident's were identified with possible serious mental disorders, to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) of 10 residents reviewed for PASARR.
- 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 facility policy review, medical record review, observations, and interviews, the facility failed to develop the comprehensive care plan for 2 residents (Resident #68 and #74) of 22 residents reviewed for care plans.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure the medical record was complete and accurate for 1 resident (Resident #68) of 22 residents reviewed for medical records.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to assist or offer 2 (Residents #76 and #10) the opportunity to perform hand hygiene before an evening meal on 1 of 2 units observed for meal service.
February 12, 2020Standard inspection · 5 citations
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to assess 1 resident (Resident #3) prior to the use of a physical restraint, and failed to assess 3 residents (Residents #60, #58, and #10) for restraint reduction of 5 residents reviewed for physical restraints.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to implement an intervention to prevent falls for 2 residents (Residents #3 and #35) of 4 residents reviewed for falls of 27 sampled residents.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to obtain laboratory tests as ordered by the physician for 1 resident (Resident #10) of 5 residents reviewed for unnecessary medications.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, the facility failed to maintain an accurate medical record for 1 resident (#39) of 32 residents reviewed for medical records.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to follow isolation procedures for 1 resident (Resident #220) of 2 residents reviewed for isolation precautions.
Fire safety inspections
7 fire safety citations on file: 4 on June 25, 2025, 1 on May 1, 2024, 2 on February 12, 2020.
Every fire safety citation7 citations
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 25, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 25, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 25, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · June 25, 2025 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 1, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 12, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 12, 2020 · Corrected (the home has a date of correction)