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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
8D
4E
2F
Potential for minimal harm
0A
0B
0C
March 24, 2025Standard inspection, Complaint inspection · 8 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 117 residents. The sample included 24 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to improper hand hygiene care by facility staff during incontinent care and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. The facility staff also failed to follow infection control policies for respiratory care and failed to follow proper enhanced barrier precautions (EBP- a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO) in nursing homes). This deficient practice had the potential to spread possible infections to the residents in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility reported a census of 117 residents. The 24 sampled residents included four dependent residents reviewed for activities of daily living (ADLs). Based on observation, interview, and record review the facility failed to provide scheduled baths in accordance with the residents scheduled bathing schedule to ensure necessary services to maintain good personal hygiene for Resident (R) 47.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteThe facility census totaled 117 residents, eleven medication carts and three medication storage rooms. Based on observation, interview, and record review, the facility failed to ensure the staff had dated multiple dose vials of injectable medication. This deficient practice placed residents at risk of receiving outdated injectable medication.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 117 residents with 24 in the sample. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to prevent possible food-borne illness among the facility's residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteThe facility reported a census of 117 residents with 24 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set for three Residents (R), which included R11's pressure injury and R18's use of a foley catheter.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThe facility had a census of 117 residents, the sample included 24 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan with interventions to address R47's preferences for bathing on the resident's comprehensive care plan.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility reported a census of 117 residents with 24 residents sampled. Based on observation, interview, and record review revealed the facility failed to hold hypotension (low blood pressure) medication for Resident (R)11.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteThe facility reported a census of 117 residents. The facility failed to provide the appropriate vegetarian diet selection sheet for a resident (R)13 who was vegetarian with orders for a vegetarian diet.
January 25, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility identified a census of 108 residents. The sample included three residents reviewed for hot liquid accidents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1, who required staff assistance with meals, remained free from preventable accidents when she spilled hot tea on herself on 12/12/23. This deficient practice resulted in a second degree burn second degree burn (potentially painful burn which affects the first and second layer of the skin and blisters) to her left thigh. This also placed the resident at risk for increased pain.
June 7, 2023Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 112 residents. The facility identified one central kitchen with four dining areas. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteThe facility reported a census of 112 residents with 23 residents sampled, including one resident reviewed for notification of change. Based on observation, interview and record review, the facility failed to notify the physician of pulses being outside of parameter, as ordered, for one Resident (R)77.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility reported a census of 112 residents with 23 residents sampled including two residents reviewed for activities of daily living (ADL). Based on observation, interview and record review, the facility failed to provide adequate ADL cares for one dependent Resident (R)20, regarding clean clothing.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThe facility reported a census of 112 residents with 23 selected for review which included four residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure pressure ulcer dressing care for one Resident (R)108, of the four residents reviewed for pressure ulcers.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteThe facility reported a census of 112 residents with 23 selected for review which included one resident reviewed for intravenous therapy. Based on observation, interview and record review, the facility failed to ensure timely dressing change for one Resident (R)15 with a peripherally inserted central catheter (PICC- a long thin tube that is inserted into a vein in the arm and ends in a vein near the heart) for intravenous infusion of antibiotics.
February 7, 2022Standard 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 wroteThe facility had a census of 97 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 94 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for foodborne illness.
Fire safety inspections
35 fire safety citations on file: 14 on March 24, 2025, 6 on June 7, 2023, 15 on February 7, 2022.
Every fire safety citation35 citations
- F
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 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 24, 2025 · Corrected (the home has a date of correction)
- F
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 24, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · 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
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 24, 2025 · Corrected (the home has a date of correction)
- F
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)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · 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 proper usage of power strips and extension cords.
K 920 · March 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
K 925 · March 24, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 7, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 7, 2023 · Corrected (the home has a date of correction)
- 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 · June 7, 2023 · Corrected (the home has a date of correction)
- 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 7, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 7, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 7, 2023 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 7, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 7, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · February 7, 2022 · Corrected (the home has a date of correction)
- E
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 · February 7, 2022 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 7, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 7, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 7, 2022 · Corrected (the home has a date of correction)