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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
5D
2E
1F
Potential for minimal harm
0A
0B
0C
April 10, 2025Standard inspection · 4 citations
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written) conveyed during resident council meetings (a meeting of the facility's residents to communicate concerns, request improvements and keep up to date of the facility's activities/events) underwent prompt resolution through to their conclusion or appropriately updated on the grievance progress/conclusion for 4 of 5 residents (Resident 22, 348, 350, 349) reviewed for the grievances process. This failure placed residents at risk for unresolved concerns and unmet care needs.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) had the required Level 2 referral sent when residents had a positive Level 1 PASARR and were an exempted hospital discharge in the facility for more than 30 days or had a change in condition in which a new Level 1 PASARR would require completion for 2 of 5 residents (Resident 24 and 2) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate to their needs.
- 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 interview and record review the facility failed to: 1) identify and monitor individualized targeted behaviors (ITB's), and implement non-pharmacological (methods used to improve health and/or manage a residents conditions without the use of medications) interventions before prescribing a psychotropic medication (a group of drugs that affect brain activities associated with mental processes and behavior), 2) monitor for adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have, that can lead to a decline in an individual's mental or physical condition); and 3) ensure appropriate justification for the use of a psychotropic medication for 1of 5 residents (Resident 19), reviewed for unnecessary medications. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff implemented appropriate infection control practices in the prevention of urinary tract infections (a condition were pathogens like bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) with residents indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) care for 1 of 2 resident (Resident 17), reviewed for infection control. This failure placed the residents at risk of developing an IUC associated UTI and unmet care needs.
December 26, 2024Complaint inspection · 1 citation
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for medication administration, was free from a significant medication error. Resident 1 experienced harm when Staff A (Registered Nurse) did not follow standard practices for medication administration when they administered multiple medications, belonging to another resident, to Resident 1. This resulted in Resident 1 becoming unresponsive with low blood pressure (BP) and low blood glucose (BG) levels, necessitating an emergency transfer to the emergency room and admission to the hospital. The facility corrected the deficient practice prior to the initiation of the abbreviated survey on 12/26/2024. This failure was past non-compliance (the facility was not in compliance at the time the situation occurred; [...]
September 4, 2024Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely care and services and perform assessments for 1 of 3 residents (Resident 1) reviewed with indwelling urinary retention catheters. Resident 1 experienced harm when they had prolonged bladder pain due to urinary retention with a delay in treatment. The facility corrected the deficient practice prior to the initiation of the abbreviated survey on 09/04/2024. This failure was past non-compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) and was corrected by the facility on 08/29/2024 and is no longer outstanding. The facility removed the noncompliance by: - Resident 1 was immediately assessed by a LN and action was taken to address their medical needs. [...]
May 13, 2024Standard inspection · 1 citation
- D
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 interview the facility failed to provide a safe, functional, and sanitary (the conditions that affect hygiene and health) environment for residents and staff for 1 of 1 shower room (SR 1), reviewed for a comfortable environment. This failure placed residents and staff at an increased risk for not feeling safe and secure with their environment.
April 21, 2023Standard inspection · 3 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, interview and record review, the facility failed to periodically test the sanitizing agent used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for food service safety, for one of one kitchen reviewed for food service safety. This failure placed all residents, staff, and visitors that ate from the facility's kitchen at risk for food borne illnesses and the spread of infectious diseases.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention and control precautions were implemented by seven of ten staff (H, D, O, I, Q) observed during dining and meal tray delivery to residents, and one of two staff (J) observed during wound care dressing changes. These failures placed residents and staff at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure clinical appropriateness for safe self-administration of medication for two of two residents (5 and 192), reviewed for medication administration. Additionally, the facility failed to obtain a physician's order for self-administration of medications for the residents and did not update the individualized care plan. Failure to complete a self-administration assessment and obtain a physician's order placed the residents at risk for medication errors and adverse medication interactions.
Fire safety inspections
21 fire safety citations on file: 3 on April 10, 2025, 13 on May 13, 2024, 5 on April 21, 2023.
Every fire safety citation21 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 10, 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 10, 2025 · Corrected (the home has a date of correction)
- D
Create arrangements with other facilities to receive patients.
E 25 · April 10, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements.
K 100 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 13, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 13, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 13, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 13, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 13, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 21, 2023 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · April 21, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 21, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 21, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 21, 2023 · Corrected (the home has a date of correction)