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
1G
0H
0I
Potential for more than minimal harm
11D
0E
0F
Potential for minimal harm
0A
0B
0C
June 27, 2025Standard inspection, Complaint inspection · 10 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, record review, and document review, the facility failed to ensure staff transferred a resident, who was at risk for falls, with the use of a mechanical lift and two-person staff assistance. Specifically, on 06/11/2024, failed to follow the resident's care plan and daily care guide when she assisted the resident with a transfer from their wheelchair to the bed. During the transfer, Resident #6 fell to the floor and sustained a right femur fracture. This deficient practice affected 1 (Resident #6) of 4 sampled residents reviewed for accidents.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide a private meeting space for the monthly Resident Council meeting that was attended to by 8 of 95 residents who resided in the facility.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to monitor the side effects and efficacy of psychotropic medications for 1 (Resident #33) of 5 sampled residents reviewed for unnecessary medications.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse to the administrator that involved 1 (Resident #54) of 8 sampled residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to complete a thorough investigation for an allegation of sexual abuse that involved 1 (Resident #207) of 8 sampled residents reviewed for abuse.
- 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 interview, record review, and facility policy review, the facility failed to develop a comprehensive person centered care plan to address dialysis for 1 (Resident #48) of 1 sampled resident reviewed for dialysis and pain 1 for (Resident #158) of 3 sampled residents reviewed for pain management.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to order prescribed medication for 1 (Resident #308) of 20 sampled residents.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to monitor the side effects and efficacy of an anticoagulant medication for 1 (Resident #33) of 5 sampled 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 interview, record review, and facility policy review, the facility failed to ensure staff documented the condition of a resident's skin for 1 (Resident #157) of 20 sampled residents.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's call light was within reach for 1 (Resident #6) of 20 sampled residents.
August 22, 2019Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review and review of facility policies titled, CONTACT PRECAUTIONS and ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES, the facility failed to ensure: 1) a Contact Isolation sign was posted on Resident Identifier (RI) #49's door on three of three days of the survey; and 2) a medication nurse did not clean RI #29's feeding syringe with a paper towel after administering medications to RI #29 during the evening medication pass on 08/21/19. These deficient practices affected RI #49, one of one resident on isolation precautions; and RI #29, one of one resident observed with a feeding tube during the medication pass administration. Findings Include: 1) Review of a facility policy titled CONTACT PRECAUTIONS, with a date of 10/09, revealed: POLICY: [...]
June 28, 2018Standard inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, review of the Controlled Record of Medication Destruction sheets and review of a facility policy titled MEDICATION DESTRUCTION, the facility failed to ensure the required signatures were on one of five Controlled Record of Medication Destruction sheets for the months of January and February 2018, and one of five Controlled Record of Medication Destruction sheets for the month of February 2018 had a date of disposal on the sheet. This affected two of 12 months of Controlled Record of Medication Destruction Records reviewed. Findings Include: A facility policy titled MEDICATION DESTRUCTION, dated 12/13, documented: . RESPONSIBILITY: All Licensed Personnel / Director of Nursing Services . CONTROLLED MEDICATIONS . 4. Medication destruction occurs only in the presence of two licensed nurses and/or a licensed nurse and a pharmacist or as required by state regulations. 5. [...]
Fire safety inspections
14 fire safety citations on file: 4 on June 27, 2025, 8 on August 22, 2019, 2 on June 28, 2018.
Every fire safety citation14 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 27, 2025 · Corrected (the home has a date of correction)
- F
Meet the requirements of an integrated health system.
E 42 · June 27, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 27, 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 · June 27, 2025 · 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 22, 2019 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 22, 2019 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 22, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · August 22, 2019 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 28, 2018 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · June 28, 2018 · Corrected (the home has a date of correction)