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 4 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
0E
1F
Potential for minimal harm
0A
0B
0C
May 12, 2025Standard inspection, Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene F880 and Administering Medication F760, the facility failed to ensure infection control processes were followed during medication pass observation for one of three nurses observed. This deficient practice had the potential to place residents at risk for infections due to cross-contamination.
December 21, 2023Standard inspection, Complaint inspection · 3 citations
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, staff interviews, and review of the Quality Assessment and Performance Improvement (QAPI) Plan 2023, the facility failed to have an effective Quality Assurance (QA) program that developed and implemented actions to repair and/or replace the flooring throughout the facility in a timely manner. This failure had the potential to affect 70 residents.
- 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, staff interviews, record review, and review of the facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, the facility failed to ensure timely repair of a wheelchair for one of 33 residents (R) (R54), who utilized a wheelchair. The facility also failed to ensure a homelike environment in R54's room and bathroom, on one of four hallways (Unit Two Hall), and in the facility entrance area. The failures had the potential to place residents at risk for the use of unsafe equipment, unsanitary conditions, and a potential for diminished quality of life. The census was 70 residents.
- D
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 observations, staff and resident guardian interviews, record review, and review of the facility policy titled F625 Bed Hold, the facility failed to ensure one resident (R) (R225), or their guardian, was provided notification of the facility's bed-hold policy upon transfer to a hospital. The facility census was 70 residents.
September 29, 2022Standard inspection · 0 citations
Fire safety inspections
10 fire safety citations on file: 3 on May 12, 2025, 6 on December 21, 2023, 1 on September 29, 2022.
Every fire safety citation10 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 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 · May 12, 2025 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · May 12, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 21, 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 · December 21, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 21, 2023 · Corrected (the home has a date of correction)
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · December 21, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 29, 2022 · Corrected (the home has a date of correction)