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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
2E
0F
Potential for minimal harm
0A
0B
1C
June 10, 2025Standard inspection · 1 citation
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards relative to a urinary catheter for one Resident (#74), of two applicable residents, out of a total sample of 20 residents. Specifically for Resident #74, the facility failed to provide care and services consistent with professional standards of practice for a suprapubic catheter (SPC: thin, flexible tube inserted through a small incision made in the lower abdomen directly into the bladder, allowing for urine drainage) when the facility staff failed to obtain Physician orders for irrigation of the SPC, and completed irrigation of the SPC, putting the Resident at risk of urinary catheter complications, contamination of equipment and infection.
April 5, 2024Standard inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for four Residents (#46, #78, #24 and #87), out of a total sample of 19 residents and three closed records reviewed. Specifically, the facility failed to: 1. For Resident #46, accurately reflect range of motion (ROM) deficits. 2. For Resident #78, accurately reflect ROM deficits and the use of an antipsychotic medication (used to treat mental health problems whose symptoms include psychosis). 3. For Resident #24, accurately code Insulin (medication used to treat Diabetes) orders. 4. For Resident #87, accurately code the discharge location.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to administer medication as ordered by the Physician for one Resident (#52) out of a total sample of 19 residents. Specifically, the facility staff failed to ensure that Midodrine (medication to treat low blood pressure [hypotension] by increasing the blood pressure) was administered according to the parameters ordered by the Physician.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that Enhanced Barrier Precautions (EBP- targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infection) were implemented in order to prevent the potential spread of infection for one Resident (#47), of one applicable resident on EBP, out of a total sample of 19 residents. Specifically, the facility staff failed to ensure that the required personal protective equipment (PPE) was worn when providing high-contact feeding tube care for Resident #47 when he/she was identified as being on EBP.
October 4, 2022Standard inspection · 4 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff: 1) Appropriately disposed of used personal protective equipment (PPE), in a manner that would not contaminate clean PPE on one unit (North 1) out of three units observed, and 2) Screened residents for signs and symptoms of COVID-19 every shift on a unit experiencing a COVID-19 outbreak for one Resident (#36) in a sample of three residents.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review, and interview, the facility and its staff failed to ensure that the medical record included documentation that education and the opportunity to consent to, receive, or decline pneumococcal immunization (a vaccine to prevent pneumonia: a potentially life threatening lung infection) was present for three Residents (#63, #64, and #74),out of five residents sampled for immunization review.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on an observation, interview and policy review, the facility and its staff failed to properly secure medications on one unit out of a total of three units. Specifically, the facility staff failed to ensure an unattended medication cart was locked, putting residents at risk for potential harm.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview the facility and its staff failed to ensure the posting of the daily staffing information reflected the current date.
Fire safety inspections
5 fire safety citations on file: 1 on June 10, 2025, 2 on April 5, 2024, 2 on October 4, 2022.
Every fire safety citation5 citations
- C
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 10, 2025 · no revisit needed
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 5, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 5, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 4, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 4, 2022 · Corrected (the home has a date of correction)