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
15D
2E
0F
Potential for minimal harm
0A
0B
0C
March 27, 2025Standard inspection · 12 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to provide care and/or services to address resident needs for two (2) of 28 current sampled residents (Resident #26 and Resident #94).
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to ensure a complete an accurate clinical record for 4 of 28 residents, Resident #38, Resident #4, Resident #68 and Resident #94.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, clinical record reviews, and facility document reviews, the facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 28 current sampled residents (Resident #90, #15, #94, and #26).
- 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 resident and staff interview, record review and facility document review, the facility staff failed to promote resident self-determination through support of resident choice related to bathing for 1 of 28 current residents in the survey sample, resident # 41.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to ensure a Durable Do Not Resuscitate (DDNR) form was signed by the ordering medical provider for one (1) of 28 sampled current residents (Resident #73).
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to notify the provider and the resident's responsible party of a change in condition for 1 of 28 current residents in the survey sample, resident # 66.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an accurate MDS assessment for 1 of 28 sampled residents (Resident #12).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wrote2. The facility staff failed to ensure Resident #73's Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability form was completed according to document guidance. Resident #73's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/7/25, was signed as completed on 1/9/25. Resident #73 was assessed as able to make self understood and as able to understand others. Resident #73's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. Resident #73's preadmission screening document, dated 12/31/24, included two (2) sections which required sub-questions in the section to be answered prior to completing the main question of the sections. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on resident interviews, staff interviews, and clinical record review, the facility staff failed to provide adequate supervision and/or monitoring in response to an accident/incident for one (1) of 28 sampled current residents (Resident #5).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the medical provider orders for 1 of 28 sampled residents (Resident #175).
- 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 wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist and failed to provide evidence of medical provider review of a drug regimen review with recommendations for 1 of 28 sampled residents (Resident #42).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on clinical record review and facility document review, the facility staff failed to ensure residents are free of significant medication errors for 2 of 28 sampled residents (Resident #69 and Resident #77).
August 25, 2022Standard inspection · 5 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interviews, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure a resident's medical provider and/or responsible party (RP) was notified of the inability to carry out a medical provider order for one (1) of 26 sampled residents, Resident #103. For Resident #103, the facility staff failed to notify the resident's medical provider and/or responsible party of the inability to carry out a medical provider's order for intravenous (IV) fluids.
- 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 wroteBased on Resident interview, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 of 21 current Resident reviews, Resident #37. Resident #37's care plan included the intervention monitor the thrill and bruit. Resident #37 had a permacath in the right subclavian area. A Permacath insertion is the placement of a special IV line into the blood vessel in your neck or upper chest just under the collarbone.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review, facility document review, and in the course of a complaint deficiency, the facility staff failed to follow a medical provider's orders for one (1) of 26 sampled residents, Resident #103. For Resident #103, the facility staff failed to follow medical provider orders for intravenous (IV) fluids.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interviews, clinical record reviews, and facility document review, the facility staff failed to ensure medical provider ordered laboratory tests were completed for one (1) of 21 sampled current residents, Resident #15. For Resident #15, the facility staff failed to obtain 'STAT' Keppra and carbamazepine levels. Resident #15 was prescribed Keppra and carbamazepine for the diagnosis of seizures. (STAT is a medical abbreviation meaning immediately or at once.)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical records for two (2) of 26 sampled residents, Resident #37 and Resident #103. For Resident #103, the facility staff failed to document attempts to administer medical provider ordered intravenous (IV) fluids. For Resident #37, the facility nursing staff were documenting they were checking the bruit and thrill and monitoring the arteriovenous (AV) shunt every shift. Resident #37 had a permacath in their right subclavian area.
March 3, 2020Standard inspection · 1 citation
- 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 staff interviews, clinical record review, and facility document review, it was determined the facility staff failed to ensure that one (1) of 24 sampled residents (Resident #81) was free from a unnecessary psychotropic medication as evidence by the administration of a psychotropic medication (lorazepam) for a reason other than the reason ordered by the provider.
Fire safety inspections
30 fire safety citations on file: 1 on March 27, 2025, 12 on August 25, 2022, 17 on March 3, 2020.
Every fire safety citation30 citations
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 27, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 25, 2022 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 25, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 25, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 25, 2022 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · August 25, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 25, 2022 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 25, 2022 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · August 25, 2022 · 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 · August 25, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 25, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 25, 2022 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 25, 2022 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Provide rooms that can be unlocked from inside without a key.
K 221 · March 3, 2020 · 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 3, 2020 · Corrected (the home has a date of correction)
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · March 3, 2020 · Corrected (the home has a date of correction)
- F
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 3, 2020 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 3, 2020 · 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 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Have power receptacles that are properly grounded.
K 912 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 3, 2020 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · March 3, 2020 · Corrected (the home has a date of correction)