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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
1E
0F
Potential for minimal harm
0A
0B
0C
June 11, 2025Standard inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed for one Resident (#187), with an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine), out of a total sample of 19 residents, to maintain his/her Foley catheter in a privacy bag to maintain their dignity.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and nutrition services relative to an altered texture diet for one Resident (#14), out of a total sample of 19 residents. Specifically, the facility failed to provide Resident #14 with thickened beverages in accordance with the Resident's plan of care, placing Resident #14 at risk for swallowing complications.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for two Residents (#188 and #10), out of a total sample of 19 residents. Specifically, 1. For Resident #188, the facility failed to ensure that Physician orders with the appropriate liter flow were obtained for oxygen use when the Resident was being administered oxygen. 2. For Resident #10, the facility failed to obtain active Physician orders for the use of PRN (as needed) oxygen with the required liter flow when the Resident was being administered PRN oxygen.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent foodborne illness to residents. Specifically, the facility failed to: 1. Ensure that food items were stored properly labeled and dated as required; and 2. Ensure that the dietary staff were wearing hair coverings in the kitchen while preparing food.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices in accordance with professional standards to prevent the potential spread of infection for one Resident (#187), out of a total sample of 19 residents. Specifically, the facility staff failed to ensure the required personal protective equipment (PPE) was adhered to when Resident #187 was admitted with a surgical abdominal wound and an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) that required Enhanced Barrier Precautions, increasing the Residents' risk for infection and preventing the potential spread of multidrug-resistant organisms (MDROs) during high-contact resident care activities.
May 17, 2024Standard inspection · 0 citations
November 14, 2022Standard inspection · 6 citations
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on test log review, and interview, the facility failed to ensure that its staff tested residents for COVID-19 at the appropriate frequency, when the facility was experiencing an outbreak of COVID-19. Specifically, staff failed to conduct testing of residents every 48 hours as required, on a unit with COVID-19 outbreak to stop the spread of infection.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure that its staff accurately executed the wishes for two Residents (#72 and #81), out of a total sample of 18 residents, and their designated Health Care Proxy (HCP-the legal document used to inform medical providers who should make decisions about care if an individual is not competent to do so) regarding advance directives (a written statement of an individual's wishes regarding medical treatment), resulting in no documented directions for an emergent status change. Specifically, 1) the facility failed to offer the opportunity to formulate an advance directive for one Resident (#72) after his/her HCP had been deactivated, and 2) failed to ensure that advance directive decisions were made by the activated HCP for one Resident (#81) who had been deemed as lacking the capacity for informed medical decision making. [...]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review, and interview the facility failed to ensure the opportunity to pay privately for a bed-hold was offered to one Resident/Resident Representative (#86), prior to a hospital transfer, out of 3 applicable sampled residents, resulting in termination of skilled rehabilitation services.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided appropriate care and services to one Resident (#52) with a Gastrostomy tube (G-tube - a tube that is placed directly into the stomach through an abdominal wall incision for enteral administration of food, fluids and medication), out of a total sample of 18 residents. Specifically, the facility failed to: 1) measure and document G-tube residual (the amount of stomach contents remaining in the stomach following administration of an enteral feed and used to monitor gastric emptying), and 2) provide appropriate treatment to the abdominal wall G-tube incision site.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, and interview, the facility staff failed to ensure that one Resident (#19) was free from unnecessary doses of an opioid medication, out of a total sample of 18 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure that one Resident (#9), out of three applicable sampled residents, was monitored for signs and symptoms of COVID-19 during an outbreak, to prevent the spread of infection.
Fire safety inspections
8 fire safety citations on file: 3 on June 11, 2025, 2 on May 17, 2024, 3 on November 14, 2022.
Every fire safety citation8 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 11, 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 11, 2025 · 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 11, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · May 17, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 17, 2024 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · November 14, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 14, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 14, 2022 · Corrected (the home has a date of correction)