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 7 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
1E
2F
Potential for minimal harm
0A
0B
0C
March 20, 2025Standard inspection · 4 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. This failure applies to all 22 residents within the skilled nursing unit of the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure that all residents were offered the pneumococcal booster vaccine. This failure applied to four (R9, R11, R12, and R19) of five residents reviewed for vaccines on the total sample of 20.
- 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 observations, interviews, and record reviews the facility failed to follow their care planning policies by not ensuring a residents baseline care plan included safety/fall interventions. This failure applies to one (R1) of four residents reviewed for accidents on the total sample of 20.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure effective fall interventions were in place and fall interventions were being followed, resulting in multiple falls. This failure applies to one (R2) of four residents reviewed for falls on the total sample of 20.
April 4, 2024Standard inspection · 0 citations
May 5, 2023Standard inspection · 3 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 observation, interview and record review, the facility failed to follow their policy on dating opened food Items and discarding expired foods in the refrigerator for 23 of 24 residents that receive meals from the dining room.
- 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 observation, interview, and record review, the facility failed to ensure that 2 of 2 residents (R1, R12) observed for contractures have hand splint/palm guard applied in the sample of 13.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its fall precautions protocol by failure to complete root cause analysis and update care plan after each fall incident occurrence to a resident who is at high risk for falls. This deficiency affects one (R18) of three residents in the sample of 13 reviewed for Fall prevention program.
Fire safety inspections
25 fire safety citations on file: 8 on March 20, 2025, 4 on April 4, 2024, 13 on May 5, 2023.
Every fire safety citation25 citations
- F
Implement emergency and standby power systems.
E 41 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 20, 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 20, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Install a two-hour-resistant firewall separation.
K 133 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · May 5, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 5, 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 5, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 5, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 5, 2023 · Corrected (the home has a date of correction)
- E
Install properly constructed windows in hallway walls or doors.
K 364 · May 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 5, 2023 · Corrected (the home has a date of correction)