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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
4E
0F
Potential for minimal harm
0A
0B
0C
February 13, 2025Standard inspection · 4 citations
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to administer intravenous (IV) antibiotic and maintain an intravenous access site according to professional standards for 1 of 1 resident sampled for IVs, of a total sample of 40 residents, (#91).
- 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 interview and record review, the facility failed to provide a written copy/summary of the initial care plan to the resident/representative for 2 of 4 residents reviewed for care plans, of a total sample of 40 residents, (#2, #97). Findings 1. Resident #2, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included chronic respiratory failure, pleural effusion, diabetes type II, difficulty walking, malignant neoplasm of nasal cavity, and repeated falls. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14 of 15. On 2/10/25 at 10:18 AM, and on 2/12/25 at 9:37 AM, resident #2 stated he had not been to a care plan meeting and was not sure if his son or granddaughter received any invitation to a care plan meeting. [...]
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enteral feeding was infused according to physician's orders for 3 of 8 residents reviewed for tube feedings from a total sample of 40 residents, (#42, #73, #84)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document medications for 1 of 7 resident reviewed, out of a total sample of 40 residents, (#222).
December 11, 2024Complaint inspection · 2 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as per physician's orders and according to accepted professional standards of practice for 8 of 8 residents reviewed for medication administration, of a total sample of 13 residents, (#6, #7, #8, #9, #10, #11, #12, and #13).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review, the facility failed to ensure documentation was complete and accurate for 1 of 5 residents reviewed, of a total sample of 13 residents, (#5).
November 9, 2024Complaint inspection · 4 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed failed to ensure a resident was assessed to self-administer medication safely for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 14 residents, (#4).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, and record review, the facility neglected to provide the appropriate care and services after a fall with injury for 1 of 2 residents reviewed for neglect, of a total sample of 14 residents, (#12).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, and record review, the facility failed to conduct a thorough investigation pertaining to a fall with fracture for 1 of 7 residents reviewed for falls, of a total sample of 14 residents, (#2).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for 1 of 7 residents reviewed for falls, of a total sample of 14 residents, (#2).
June 29, 2023Standard inspection · 3 citations
- E
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 observation, interview, and record review the facility failed to implement a system to monitor and reconcile Pharmacy Recommendations to ensure all residents were being reviewed monthly for 3 of 5 residents (#37, #46, #22) and failed to implement a pharmacy recommendation for 1 of 5 residents reviewed (#16) reviewed for Unnecessary Medication Regimen Review, of a total sample of 37 residents.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, and record review, the facility failed to report an alleged violation of verbal abuse for 1 of 2 residents reviewed for abuse of a total sample of 37 residents, (#77).
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review the facility failed to ensure a Discharge Return Not Anticipated Minimum Data Set (MDS) assessment was completed within 14 days and submitted to the Centers for Medicare and Medicaid Services (CMS) after a resident was discharged from the facility for 1 of 1 resident identified for Resident Assessment review of a total sample of 37 residents, (#54).
August 11, 2021Standard inspection · 2 citations
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review and interview, the facility failed to maintain the dumpster area in a sanitary manner and ensure the dumpster lids remained closed, to prevent the harborage and feeding of pests.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were ordered timely upon admission. The facility also failed to get physician authorization for giving medication outside of the prescribed time for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 49 residents (resident #156).
Fire safety inspections
14 fire safety citations on file: 2 on February 13, 2025, 10 on June 29, 2023, 2 on August 11, 2021.
Every fire safety citation14 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 13, 2025 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 11, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 11, 2021 · Corrected (the home has a date of correction)