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
1G
0H
0I
Potential for more than minimal harm
9D
1E
0F
Potential for minimal harm
0A
0B
0C
April 11, 2025Standard inspection, Complaint inspection · 5 citations
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to promote and facilitate residents' self-determination through a resident's choice of clothing for one of one sampled residents (#9). This deficient practice could lead to residents having feelings of unimportance and lack of dignity. Findings Include: Resident #9 was admitted on [DATE] with diagnoses that included history of transient ischemic attack, and cerebral infarction, protein-calorie malnutrition, major depressive disorder, chronic obstructive pulmonary disease, cognitive communication deficit and chronic instability of knee. A quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #9 had a Brief Interview of Mental Status (BIMS) of 10, indicating moderate cognitive impairment. [...]
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure the views and grievances of the resident council were acted upon promptly regarding wheelchair cleaning. This deficient practice could lead to the resident council not feeling heard and issues not being resolved in a timely manner.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure that one of one sampled resident's (#32) was free from abuse. The deficient practice could result in other residents being abused.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure pain management was provided, consistent with resident preferences, for one of one sample residents (#9). This deficient practice could lead to residents experiencing poorly controlled pain.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that glucometer controls were consistently completed. The risk could result in inaccurate blood sugar results and possible inaccurate insulin administration. Findings Include: A medication storage observation was conducted on April 10, 2025 at 12:25 p.m with the Assistant Director of Nursing (ADON/Staff #56 ). During the observation of medication cart #1, a March 2025 Quality Control Record sheet revealed that glucometer controls were not performed consistently on the following dates: -March 3-5, 8-11, 19, 22, 26, 2025. During the observation an interview was immediately conducted with the ADON on April 10, 2025 at 12:40 p.m, who stated that she expected glucometer quality controls to be performed daily by a night shift nurse. [...]
June 26, 2024Standard inspection · 0 citations
December 29, 2022Standard inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure a safe transfer using a Hoyer lift for one resident (#91). The deficient practice resulted in a fall with major injury.
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on facility documentation, staff interviews, and policy review, the facility failed to ensure that three staff members (#18, #42 and #58) were tested for COVID-19 at the required frequency during an outbreak status. The deficient practice could result in spread of COVID-19 infection to residents and staff.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility documentation, closed clinical record review, staff interview, and policy review, the facility failed to report an allegation of abuse to the State Agency (SA) within the required time frame for one resident (#20). The deficient practice could result in further allegations of abuse/neglect not being reported timely.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on resident and staff interviews, clinical record, review of facility documentation and policy, the facility failed to ensure a baseline care plan was completed for one resident (#241). The deficient practice could result in the resident not receiving the care and services needed to treat their health conditions.
- 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, staff interviews, and policy and procedures, the facility failed to ensure food items available for resident use were properly sealed, marked and dated and were not expired or outdated. The deficient practice could result in foodborne illness and food not safe for consumption.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on personnel file review, staff, interviews, facility documents and policy and procedures, the facility failed to provide in-service training for two direct care staff (#59 and #40). The deficient practice could result in staff not competent in providing the necessary care and services for residents.
Fire safety inspections
13 fire safety citations on file: 2 on April 11, 2025, 3 on June 26, 2024, 8 on December 29, 2022.
Every fire safety citation13 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 11, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 26, 2024 · 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 26, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 26, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 29, 2022 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · December 29, 2022 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · December 29, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 29, 2022 · 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 · December 29, 2022 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 29, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 29, 2022 · Corrected (the home has a date of correction)
- D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · December 29, 2022 · Corrected (the home has a date of correction)