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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
0E
0F
Potential for minimal harm
0A
0B
0C
May 28, 2025Standard inspection · 6 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 5 of 7 (Resident #31, #50, #248, #498 and #501) sampled residents reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct thorough fall investigations to identify all contributing factors (root causes) and failed to implement appropriate interventions to ensure resident safety. Resident #498 was admitted on [DATE] and had 13 falls from [DATE] through [DATE]. On [DATE], Resident #498 sustained 3 falls, that resulted in a subdural hemorrhage, a C5 fracture (cervical neck fracture) and bilateral rib fractures. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote dignity for 1 of 5 (Resident #36) sampled residents reviewed for activity of daily living (ADL) care when they failed to provide hair care.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on review of resident trust accounts, policy review, medical record review, and interview, the facility failed to notify the family and/or resident when the amount in the residents' account exceeded the eligibility limit for 2 of 20 (Resident #2 and #31) residents personal fund account statements reviewed.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interview, the facility failed to report alleged violations involving abuse and injury of unknown source for 2 of 19 (Resident #28 and #82) sampled residents reviewed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on policy, medical record review, observation, and interview, the facility failed to follow Physician's Orders for oxygen for 1 of 1 (Resident #14) sampled residents reviewed for respiratory care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation and interview, the facility failed to ensure infection control practices were followed during medication administration for 2 of 8 (Resident #8 and #22) residents observed for Medication Administration when 2 of 7 nurses (Licensed Practical Nurse (LPN) A and LPN B) failed to sanitize reusable equipment.
September 6, 2019Standard inspection · 1 citation
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 27 opportunities, resulting in an error rate of 7.4074074074 %.
October 9, 2018Standard inspection · 0 citations
Fire safety inspections
11 fire safety citations on file: 5 on May 28, 2025, 1 on September 6, 2019, 5 on October 9, 2018.
Every fire safety citation11 citations
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 28, 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 28, 2025 · Corrected (the home has a date of correction)
- D
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 · May 28, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · May 28, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 28, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · September 6, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 9, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 9, 2018 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · October 9, 2018 · Corrected (the home has a date of correction)
- C
Establish policies and procedures including evacuation.
E 20 · October 9, 2018 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · October 9, 2018 · Corrected (the home has a date of correction)