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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
12D
0E
4F
Potential for minimal harm
0A
0B
1C
March 5, 2025Standard inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 38 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 38 residents. Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for the residents of the facility, in two of four resident halls.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThe facility reported a census of 38 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to complete a resident centered comprehensive care plan for one Resident (R) 14, regarding non-pharmacologic interventions for pain.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteThe facility reported a census of 38 residents with 15 residents sampled, including one resident reviewed for pain. Based on observation, interview and record review, the facility failed to offer non-pharmaceutical interventions for pain for one Resident (R)17, who has chronic pain.
- 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 wroteThe facility reported a census of 38 residents with 15 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor five Residents (R) 26, and R 34, regarding failure to monitor the side effects of psychotropic (drugs that affect the brain and central nervous system, altering mood, thoughts, emotions, and behavior) and antipsychotic (drugs that treat psychotic symptoms like hallucinations and delusions) medications and the failure to obtain a stop date for R 18's antianxiety (drugs that treat anxiety disorders) medication, Ativan.
- C
Post nurse staffing information every day.
Inspectors wroteThe facility reported a census of 38 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily, for the 38 residents who reside in the facility.
June 14, 2023Standard inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility census totaled 31 residents with 12 residents in the sample, including two residents sampled for accident hazards. Based on observation, interview, and record review, the facility failed to provide timely and appropriate interventions to prevent further falls for Resident (R) 28. The resident had a history of multiple falls and fell while attempting to self-toilet and sustained a fractured humerus (bone of the upper arm).
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 31 residents. The facility had one main kitchen. The kitchen served food to one main dining area. Based on observation, interview, and record review, the facility failed to properly store food in the main kitchen refrigerators due to foods left uncovered, boxes placed directly on the floor in the freezer and dry storage area, and staff failed to discard expired foods in accordance with professional standards for food service safety, to prevent food borne illness to the residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteThe facility census totaled 31 residents with 12 included in the sample. Based on interview and record review, the facility failed to revise care plans for Resident (R) 28, related to falls.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility reported a census of 31 residents, with 12 sampled, including one resident sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide care consistent with standard of practice for the one sampled Resident (R) 30 to maintain good grooming and personal hygiene related to showers, nail care, and facial hair removal.
- 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 wroteThe facility reported a census of 91 residents. The sample included 12 residents, with one resident sampled for bowel/ bladder incontinence. Based on observation, interview, and record review, the facility failed to provide an individualized toileting plan for Resident (R) 28, to ensure the resident remained as continent as possible.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility reported a census of 31 residents with 12 residents included in the sample which included five residents selected for review of influenza, pneumococcal, and COVID vaccines. Based on interview and record review, the facility failed to ensure the resident/resident representative received information/education regarding the benefits, risks, or medical contraindications of pneumococcal for three Residents (R), including R26, R23 and R35.
November 4, 2021Standard inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 35 residents. The facility had one main kitchen where food was stored and prepared for one dining room. Based on observation, interview, and record review the facility failed to store and prepare food under sanitary conditions when the facility failed to properly store food items, clean kitchen equipment, ensure refrigerator and freezer temperature were documented and dietary staff did not properly restrained hair. These failures affected all the residents of the facility.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThe facility census totaled 35 residents, with 12 included in the sample. Based on interview and record review the facility failed to develop a comprehensive care plan to include the use of oxygen (O2) for Resident (R)23.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteThe facility reported a census of 35 resident, with 12 included in the sample, and one resident reviewed for discharge. Based on interview and record review the facility failed to document a recapitulation of the resident's stay upon discharge for the Resident (R) 41.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility census totaled 35 residents, with 12 included in the sample, and five residents reviewed for oxygen (O2) use. Based on observation, interview, and record review the facility failed to provide necessary respiratory care and/or services consistent with professional standards of practice when they failed to change disposable O2 equipment for Resident (R)23 and R27.
- 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 wroteThe facility census totaled 35 residents with five residents reviewed for unnecessary medications. Based on interview and record review the facility failed to ensure the pharmacist identified and reported missing documentation concerning physician notifications for blood pressures that exceeded parameters for Resident (R)35 and R36.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility census totaled 35 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of blood pressure medication for Resident (R)35, and R36. The facility License Nurse (LN) staff did not notify the physician of elevated blood pressures which exceeded the physician ordered parameters for R35 and R36.
Fire safety inspections
31 fire safety citations on file: 9 on March 5, 2025, 6 on June 14, 2023, 16 on November 4, 2021.
Every fire safety citation31 citations
- F
Use approved construction type or materials.
K 161 · March 5, 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 · March 5, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2025 · Waiver
- F
Install corridor and hallway doors that block smoke.
K 363 · March 5, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 5, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 5, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 5, 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 · March 5, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 5, 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 · June 14, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 14, 2023 · 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 · June 14, 2023 · 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 14, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 14, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 14, 2023 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · November 4, 2021 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · November 4, 2021 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · November 4, 2021 · 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 4, 2021 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 4, 2021 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 4, 2021 · Corrected (the home has a date of correction)