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 9 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
2E
0F
Potential for minimal harm
0A
0B
0C
June 12, 2025Standard inspection · 0 citations
March 21, 2024Standard inspection · 4 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 28 sampled residents to self-administer medications. (Resident #80)
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop an accurate care plan for 1 of 1 residents sampled for dental concerns. (Resident #100)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interview the facility failed to provide a respiratory care and services for 1 of 1 resident sampled. (Resident #104)
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to honor a resident's request for a different meal choice for 1 of 2 sampled residents reviewed for food. (Resident #88)
January 13, 2023Standard inspection · 5 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to provide adequate supervision of a vulnerable resident identified to be at risk for elopement due to exit seeking, by allowing the resident to exit the facility unescorted by staff, and subsequently leave the facility grounds with a visitor unknown to the resident. This affected Resident #90 who was 1 of 2 sampled residents reviewed for accidents and supervision. The facility staff failed to intervene or report to nursing staff when the visitor reported to the receptionist that he was going to escort the resident across the street to the emergency room per the resident's request on 1/1/23 at approximately 5:50 PM. [...]
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on record review, staff interviews, and Administrator job description review, the facility failed to utilize its resources effectively to develop and implement policies to ensure resident safety is maintained when residents leave the facility with other individuals and to ensure the appropriate staff are aware of the resident's departure from the facility. This has the potential to affect all residents in the facility who exit the facility for leave of absence. (Cross reference F689).
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review, staff interviews, quality assurance performance improvement plan review, and policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to supervision of residents with cognitive impairment, a process to ensure resident safety when leaving the facility with visitors and educating staff and visitors of such process for 1 of 2 residents sampled for accidents and supervision.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to implement the plan of care for 1 of 2 residents reviewed for accidents and supervision. (Resident #90)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interviews, record review, and policy review, the facility failed to ensure staff followed appropriate isolation precautions during the provision of housekeeping services for 1 of 1 sampled residents on transmission-based precautions. (Resident # 209)
Fire safety inspections
2 fire safety citations on file: 1 on June 12, 2025, 1 on March 21, 2024.
Every fire safety citation2 citations
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · June 12, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 21, 2024 · Corrected (the home has a date of correction)