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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
19D
3E
4F
Potential for minimal harm
0A
0B
4C
April 28, 2025Standard inspection, Complaint inspection · 13 citations
- F
Have policies on smoking.
Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure smoking safety was followed on facility grounds per facility policy. This had the potential to affect all 55 residents of the facility. The census was 55. Findings Include: Observation on 04/28/25 at 9:57 A.M. of the facility parking lot with Maintenance Director (MD) #511 revealed cigarette butts disposed of in mulch beds. The mulch bed nearest the facility dumpsters contained 17 cigarette butts. The mulch bed nearest the wooden [NAME]-cochere (a covered porch where vehicles can pick up and drop off people) at the main entrance contained 10 cigarette butts. The trash can under the [NAME]-cochere was observed to have ash marks on the sides of it from cigarettes being extinguished and the inside of the trash can was observed to contain flammable materials. [...]
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, resident and staff interview, and review of a bid quote for work from a local construction company, the facility failed to provide a safe and homelike environment. This affected 18 (#4, #6, #8, #10, #15, #17, #18, #19, #22, #23, #25, #36, #37, #38, #39, #42, #46, and #50) of 55 residents reviewed for environment. The facility census was 55. Findings Include: 1. Interview with Resident #19 in the facility's outdoor smoking area on 04/22/25 at 9:50 A.M. revealed the resident did not feel safe in the smoking area and felt it was only a matter of time before the wooden [NAME] structure surrounding the smoking area was going collapse around the residents. Observation of the smoking area on 04/22/25 at 10:00 A.M. revealed the area was covered by a wooden [NAME]. The wood on the structure beams were noted to be visibly rotting to various degrees all throughout the area. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were transported in the facility in a dignified and respectful manner. This affected one (#37) of one residents reviewed for respect and dignity. The facility census was 55. Findings Include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses that included cocaine abuse, sepsis, and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and required assistance of one staff person for completing his activities of daily living including bathing. Observation of Resident #37 on 04/21/25 at 11:44 A.M. revealed Resident #37 was sitting on a shower chair being pulled by Certified Nurse Aide (CNA) #608 to his room. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the resident or resident representatives with the name and telephone number of the appeal agency. This affected two (#5 and #8) of three residents reviewed for beneficiary notices. The facility census was 55.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, review of the medical record, and staff interview, the facility failed to ensure a resident was properly assessed for use of a restraint. This affected one (#18) of three residents reviewed for restraints. The census was 55.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (PASARR) assessments were updated and accurate. This affected one (#52) of two residents reviewed for PASARR assessments. The facility census was 55. Findings Include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that include dementia, schizophrenia, high cholesterol, and retention of urine. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was severely cognitive impaired and required extensive assistance of one staff person for completing his activities of daily living. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the medical record, review of narcotic count sheet, and resident and staff interview, the facility failed to ensure medications were available as ordered to treat pain. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review, pharmacy recommendation review, and staff interview, the facility failed to act upon pharmacist recommendations that were agreed to by the residents physicians as required. This affected two (#51 and #54) of five residents reviewed for unnecessary medications. The facility census was 55. Findings Include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors. [...]
- 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 medical record review, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure appropriate indications and/or diagnoses were in place for residents receiving antipsychotic medication. This affected one (#51) of five residents reviewed for unnecessary medications. The facility census was 55. Findings Include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of the medical record and interview with staff, the facility failed to ensure a resident was given insulin as ordered. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, review of the medical record, and interview with the staff, the facility failed to ensure residents were provided thickened liquids as ordered. This affected one (#29) of three residents reviewed for nutrition. The census was 55.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to maintain proper infection control measures during wound care and bed linen changes. This affected two (#29 and #33) of two residents observed for proper infection control measures maintained during care and services. The census was 55.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation of the posted survey results, review of previous survey history, and staff interview, the facility failed to ensure posted survey results were updated with the most recent survey results. This had the potential to affected all 55 residents. The facility census was 55.
April 26, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, review of QSO-24-08-NH and review of facility policy, the facility failed to ensure enhanced barrier precaution (EBP) guidelines were followed for all residents that required EBP. This affected five of ten residents (Resident #1, #23, #50, #51, #57) reviewed for EBP. The facility census was 59. Findings Include: 1. Review of the medical record for Resident #23 revealed and admission date of 12/07/23. Diagnoses included respiratory disorders, tracheostomy, morbid obesity and acute respiratory failure with hypoxia. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 was on oxygen, required suctioning, had a tracheostomy and required a mechanical ventilator for respiratory support. [...]
November 17, 2023Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to timely address a resident change in condition. This affected one resident (Resident #65) of three residents reviewed for notification of changes. The facility census was 62.
October 24, 2022Standard inspection · 8 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care planned interventions were in place to prevent falls for Resident #11, Resident #53, Resident #37 and Resident #20. Actual harm occurred when Resident #11 and Resident #53 suffered a fall with a fracture nose and right femur respectively and were admitted to the hospital. This affected four residents (Resident #11, Resident #20, Resident #37, and Resident #53) out of six residents reviewed for falls. The facility census was 57.
- 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 ensure a clean and sanitary kitchen area and ensure appropriate glove usage. This had the potential to affect all 57 of 57 residents receiving meals from kitchen, as the facility identified no residents with nothing by mouth diet orders.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #11 and Resident #53's room was uncluttered to maintain a safe environment. This affected two residents (Resident #11 and Resident #53) out of 57 residents reviewed for accommodation of needs. The facility census was 57.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and medical record review, the the facility failed to properly treat Resident #21's constipation. This affected one resident (Resident #21) out of one resident reviewed for constipation.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #24's pressure ulcer treatment was completed as ordered. This affected one resident (Resident #24) out of one resident reviewed for pressure ulcers.
- 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 record review and interview the facility failed to maintain Resident #30's right hand splint to prevent contracture. This affected one out of four residents reviewed for limited range of motion. The facility census was 57.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure Resident #37 and #43 had nutritional interventions implemented timely. This affected two residents (Resident #37 and Resident #43) out of four residents reviewed for nutrition.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and facility policy and procedure review, the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 6.9% and included two medication errors of 29 medication administration opportunities. This affected two residents (#11 and #26) of six residents observed during medication administration.
November 26, 2019Standard inspection · 8 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 and staff interview the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner and that all food was labeled, dated and stored properly. This had the potential to affect all residents. The facility census was 50.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews and record review, the facility failed to ensure infection control practices were followed for isolation precautions for one resident (Resident #31) with clostridium difficile (C-diff). This had the potential to affect all 50 residents who resided in the facility.
- E
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 staff interview the facility failed to maintain a clean and sanitary environment for Residents #5, #6, #10, #11, #12, #13, #14, #17, #18, #20, #28, #35, #38, #40, #148, #248. This affected 16 of 50 residents.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure personal resident information was communicated in a way to protect the confidentiality of the information and the dignity of the resident. This affected one of 50 facility residents, Resident #31. Facility census was 50.
- 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 record review and staff interview, the facility failed to ensure as needed (PRN) medication orders for psychotropic drugs were limited to 14 days and failed to timely follow pharmacy recommendations. This affected one Resident (Resident #27) of five residents reviewed for unnecessary medications.
- C
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on resident and staff interview the facility failed to ensure mail was delivered to residents on Saturdays. This affected five residents (Residents #11, #34, #36, #45 and #249) and had the potential to affect all 50 residents residing in the facility.
- C
Post nurse staffing information every day.
Inspectors wroteBased on record review and staff interview the facility failed to ensure posted nursing staff information was updated timely. This had the potential to affect all residents. The facility census was 50.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview the facility failed to ensure the garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all 50 residents residing in the facility.
Fire safety inspections
18 fire safety citations on file: 5 on April 28, 2025, 7 on October 24, 2022, 6 on November 26, 2019.
Every fire safety citation18 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 28, 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 · April 28, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · October 24, 2022 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 24, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 24, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 24, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 24, 2022 · 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 · October 24, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 24, 2022 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 26, 2019 · 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 · November 26, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 26, 2019 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · November 26, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 26, 2019 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 26, 2019 · Corrected (the home has a date of correction)