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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
0E
2F
Potential for minimal harm
0A
0B
0C
July 31, 2025Standard inspection · 3 citations
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living among all residents. Findings Include:On 07/30/2025 at 10:27 AM, it was noted that the drain line on the ice machine in the main dining room off the kitchen had black slime growing on end of the pipe. Maintenance Director F observed the drain pipe, and stated he cleans the ice machine and the drain tray weekly, but not the drain line that hangs above the floor drain. On 7/29/25 at 10:31 AM, the register cover in room [ROOM NUMBER] was observed dirty with brown splatters on the wall and had been re-enforced to hold the front and the top of the unit together. [...]
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure the physician documented the clinical rationale and duration of use in the medical record for a PRN (as needed) psychotropic medication for one Resident (#6) of five residents reviewed for unnecessary medications.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#2) of one resident reviewed for PASARR (Preadmission screening/Annual Resident Review) had a Level one (1) OBRA (Omnibus Budget Reconciliation Act) screening sent to the Community Mental Health Services Program (CMHSP) for a level two (2) OBRA evaluation.
August 7, 2024Standard inspection · 5 citations
- G
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 ensure a mobility bar was properly fixated to a bed frame for one resident (Resident #21) of 6 residents reviewed for accident hazards and bed safety. This deficient practice resulted in two separate falls from bed resulting in a concussion and a hip fracture requiring surgical intervention.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely administered in an environment of a residents choosing for one Resident (R191) of twelve residents reviewed for Residents' Rights.
- 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 assistance was provided with donning a back brace for one Resident (R20) of four residents reviewed for range-of-motion and mobility.
- 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: 1. Document the rationale for declining gradual dose reductions for an antipsychotic medication for one Resident (R1) of five residents reviewed for unnecessary medications, and 2. Document the rationale and duration of PRN use of a psychotropic medication for one Resident (R6) of five residents reviewed for unnecessary medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were appropriately administered for two Residents (R4 and R17) of four residents reviewed for infection control practices during medication administration.
September 21, 2023Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive, facility-wide Infection Control Program as evidenced by failure to: 1. Don, doff, and disinfect PPE (personal protective equipment) for residents with confirmed or suspected of COVID-19 infection. 2. Assess for COVID-19 symptoms and implement transmission-base precautions timely. 3. Complete infection control analysis, correlation, and trending of resident and staff infections. 4. Maintain timely and accurate infection control line listings and surveillance mapping. 5. Properly retrieve meal room trays from COVID-19 positive rooms. 6. Ensure disinfectant chemicals used to clean and disinfect transmission based precaution (TBP) rooms met the minimum concentration specified by the vendor of the chemical. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent, for two Residents (#2 & #7) of five residents reviewed for medication administration. This deficient practice resulted in lack of assessments to determine efficacy of respiratory medications and the potential for undesirable therapeutic effects from inaccurate insulin administration.
Fire safety inspections
21 fire safety citations on file: 3 on July 31, 2025, 17 on August 7, 2024, 1 on September 21, 2023.
Every fire safety citation21 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 31, 2025 · no revisit needed
- F
Have correct number of accessible exits for each story.
K 241 · July 31, 2025 · no revisit needed
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 31, 2025 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 7, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · August 7, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · August 7, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 7, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 7, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 7, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 7, 2024 · Waiver
- D
Have correct number of accessible exits for each story.
K 241 · August 7, 2024 · Waiver
- E
Have correct number of accessible exits for each story.
K 241 · September 21, 2023 · Corrected (the home has a date of correction)