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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
15E
1F
Potential for minimal harm
0A
0B
0C
July 10, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was reported to the state agency within the 2 hour required time frame for 2 (#2 and #5) of 3 sampled residents reviewed for abuse. The DON identified 67 residents resided in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 2 (#2 and #5) of 3 sampled residents reviewed for abuse. The DON identified 67 residents resided in the facility.
May 15, 2025Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote1. On 04/21/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise residents with exit seeking behaviors. On 04/14/25 Resident #14 was observed to leave the courtyard by a resident, from an unlocked gate, staff were notified and were able to redirect Resident #14 back into the building. Based on record review and interview, the facility failed to provide supervision for 1 (#14) of 1 sampled resident reviewed for exit seeking behaviors. The DON identified 66 residents resided at the facility.
November 26, 2024Standard inspection · 2 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were followed during dining services. The administrator identified 62 residents received meals from the kitchen.
- 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 record review and interview the facility failed to provide information to formulate an advance directive for three (#33, #38, and #41) of three sampled residents who were reviewed for advance directives. The administrator identified 66 residents resided in the facility.
November 1, 2023Standard inspection, Complaint inspection · 8 citations
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interview, the facility failed to ensure a facility assessment was completed annually. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility.
- E
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 and interview, the facility failed to ensure the care plan was implemented related to smoking for one (#13) of one sampled residents whose care plans were reviewed for smoking. The DON identified 20 residents who smoked.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure skin assessments were conducted for one (#34) of three sampled residents who were reviewed for pressure ulcers. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/24/23, documented 64 residents resided in the facility.
- E
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 record review and interview, the facility failed to ensure behavior and side effect monitoring was conducted for one (#45) of five residents who were reviewed for unnecessary medications. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria and have an effective and consistent infection surveillance program. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure influenza and pneumococcal vaccines were offered for two (#57 and #58) of five sampled residents reviewed for vaccines. The Long Term Care Facility Application for Medicare and Medicaid documented 64 residents resided in the facility.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to return prescription medications for one (Resident #65) of one resident whose clinical record was reviewed for misappropriation of property. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/24/23, documented 64 residents resided in the facility.
December 16, 2021Standard inspection · 9 citations
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to ensure liability notices were provided to residents discharged from skilled services with days remaining for three residents (#200, 201, and #202) of three liability notices were reviewed. The Administrator reported 12 residents who were discharged from skilled services with days remaining in the past three months.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bathing was provided for three residents (#38, 57, and #51) of 18 sampled residents reviewed for bathing. The Resident Census and Conditions of Residents form documented 67 residents resided in the facility.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review the facility failed to ensure the facility had adequate staffing to meet the needs of the residents. The DON reported a census of 67 residents.
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the director of nursing was a registered nurse. The Administrator identified a census of 67 residents.
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services as ordered by the physician for one resident (#38) of five whose laboratory services were reviewed. The Resident Census and Conditions of Residents form documented 67 residents resided in the facility.
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food temperatures were obtained prior to passing food trays to residents. The DM reported 67 residents who received meals from the kitchen.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, the facility failed to serve residents' food at palatable temperatures. The DON identified 67 residents who received meals from the kitchen.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview the facility failed to ensure sanitary conditions were maintained in the kitchen. The facility failed to: a. ensure the kitchen walls were clean. b. ensure the kitchen doors were clean and closed correctly. On 12/13/21 at 9:58 a.m., during the initial tour of the kitchen, the white walls were observed to have had large amounts of greasy black and brown splatters and spots throughout the kitchen walls. The interior door entering the kitchen from the dining area was observed to have had greasy black splatters on the inside of the door and the door did not shut properly, which allowed gaps. The exterior door had large black splatters, did not shut without being latched, and daylight was observed around the edges with multiple large holes at the bottom of the door. Debris of dead leaves was observed on the door threshold of the kitchen floor. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pre and post dialysis assessments were performed for one (#30) of two sampled dialysis residents. The DON reported three residents who received dialysis.
Fire safety inspections
17 fire safety citations on file: 2 on November 26, 2024, 9 on November 1, 2023, 6 on December 16, 2021.
Every fire safety citation17 citations
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · November 26, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 26, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · November 1, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 1, 2023 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · November 1, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 1, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 1, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 1, 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 · November 1, 2023 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 1, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 1, 2023 · 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 · December 16, 2021 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 16, 2021 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · December 16, 2021 · 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 · December 16, 2021 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · December 16, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 16, 2021 · Corrected (the home has a date of correction)