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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
1E
0F
Potential for minimal harm
0A
0B
0C
September 25, 2025Standard inspection · 2 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 3 of 3 residents reviewed for self-administration of medications, of a total sample of 41 residents, (#8, #86 & #113).1. Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, acute kidney failure, unspecified glaucoma, type 2 diabetes mellitus, blindness to the left eye and dysphagia. A review of the Minimum Data Set (MDS) admission Five-day assessment with assessment reference date (ARD) of 6/19/25 revealed resident # 8 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact. The MDS assessment revealed the resident had no behaviors, nor rejection of care and her vision was highly impaired. [...]
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained.
May 9, 2024Standard inspection · 7 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure blood glucose monitors were cleaned and disinfected appropriately between resident use to prevent the potential for transmission of blood borne pathogens on 1 of 3 Units, (Unit 200), failed to ensure appropriate Personal Protective Equipment (PPE) was donned as required prior to room entry for 1 of 1 resident on Transmission Based Precautions (TBP), (#165), failed to ensure indwelling catheter drainage bag was kept off the floor to prevent the potential of infection for 1 of 1 resident reviewed for indwelling catheter, (#165), and failed to ensure proper handling of glassware by staff during dining, of a total sample of 41 residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was completed, failed to obtain a physician's order for self-administration of medications, and failed to ensure medications were stored securely at the resident's bedside for 1 of 5 residents reviewed for choices, of a total sample of 41 residents, (#51).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to refer a resident with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 4 of 4 residents reviewed for PASARR, of a total sample of 41 residents, (#24, #47, #59 and #93).
- 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 interview and record review the facility failed to develop a baseline care plan for nutrition in the required timeframe for 1 of 4 residents reviewed for nutrition, of a total sample of 41 residents, (#165).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to identify an accurate diagnosis for anti-psychotic medication use for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 41 residents, (#71).
- 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 interview and record review, the facility failed to indicate the duration of as needed (PRN) anti-anxiety/anxiolytic medications for 1 of 5 residents reviewed for unnecessary medications and psychotropic medications, of a total sample of 41 residents, (#47).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review, the facility failed to ensure documentation in the medical record was complete and accurate according to accepted professional standards and practices regarding self-administration of medications for 1 of 5 residents reviewed for choices, of a total sample of 41 residents, (#51).
February 8, 2023Standard inspection · 3 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper administration of medications for 1 resident assessed for self-administration of medications of a total sample of 33 residents (#84). Findings Resident #84's medical record reflected an admission date of 3/20/22 and diagnoses including heart failure, cardiomyopathy, chronic obstructive pulmonary disease, rheumatoid arthritis, and anxiety. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 12/23/22 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted the resident required supervision with assistance of one person for toileting and bathing. On 2/07/23 at 9:08 AM, resident #84 sat on the side of her bed with her overbed table in front of her with medications spread out on the table. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, the facility failed to assist a dependent resident with Activities of Daily Living (ADL) care related to the cleaning of nails for 1 resident reviewed for ADL care of a total sample of 33 residents (#176).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to change wound dressing per physician orders for 1 of 3 residents reviewed for skin conditions of a total sample of 33 residents (#104).
Fire safety inspections
3 fire safety citations on file: 1 on May 9, 2024, 2 on February 8, 2023.
Every fire safety citation3 citations
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 8, 2023 · Corrected (the home has a date of correction)