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
0G
0H
0I
Potential for more than minimal harm
5D
4E
0F
Potential for minimal harm
0A
3B
0C
February 12, 2025Standard inspection · 4 citations
- E
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 record review and interview, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Activities of Daily Living (ADL's) to meet the preferences and goals which included interventions for assistance needed for each resident to attaining or maintaining his or her highest practicable quality of life for 6 of 14 residents care plans reviewed. (Residents 6, 11, 21, 47, 55, 26, and 61)
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record reviews, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 2 of 2 units reviewed.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interviews, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 3 medication storage refrigerators.
- B
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 observations and interviews, the facility failed to maintain a clean, comfortable and homelike environment on 2 of 2 units.
October 1, 2024Complaint inspection · 3 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 residents records reviewed during complaint investigations (Resident 2).
- 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 record reviews, interviews, and facility policy, the facility failed to implement interventions outlined in resident's care plan in the area of Activities of Daily Living (ADL) for 1 of 5 residents reviewed during complaint investigations. (Resident 2).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection on 1 of 2 rooms observed (room [ROOM NUMBER]).
November 15, 2023Standard inspection, Complaint inspection · 2 citations
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure proper medication and biological storage temperatures for 2 of 3 medication refrigerators in 1 of 2 medication storage rooms.
- D
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 observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair and sanitary condition of arm rests of resident's wheelchair, ceiling tiles in hallways and common areas, and thresh-hold of elevator entrance.
March 2, 2022Standard inspection · 3 citations
- D
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 observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, on 2 of 2 floors (First and Second), and hallways, for 1 of 1 environmental tour.
- B
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and interview, the facility lacked evidence of a written transfer notice indicating rationale for a facility-initiated transfer for 3 of 3 residents reviewed for transfer (#7, #8 and #51).
- B
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 issue a bed hold notice which included the daily bed hold cost, to a resident, known family member or legal representative for 3 of 3 sampled residents who had been transferred to the hospital (#7, #8 and #51).
Fire safety inspections
25 fire safety citations on file: 2 on February 26, 2025, 11 on February 12, 2025, 9 on November 15, 2023, 3 on March 2, 2022.
Every fire safety citation25 citations
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 26, 2025 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 26, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 12, 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 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 12, 2025 · Corrected (the home has a date of correction)
- D
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 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 12, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 12, 2025 · Corrected (the home has a date of correction)
- F
Construct fire resistant interior walls.
K 331 · November 15, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · November 15, 2023 · 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 · November 15, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 15, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 15, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · November 15, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 15, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 15, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of flammable curtains.
K 751 · November 15, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · March 2, 2022 · 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 · March 2, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 2, 2022 · Corrected (the home has a date of correction)