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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
3E
0F
Potential for minimal harm
0A
0B
0C
June 13, 2025Standard inspection, Complaint inspection · 3 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review, interviews, and policy, the facility failed to provide one resident (#21) and/or the resident's representative with bed-hold policy information before a transfer to the hospital. The deficient practice could result in residents being unaware of their bed-hold rights.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for one resident (#89). The deficient practice can result in residents not receiving care of activities of daily living to maintain highest practicable welbeing.
- D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on clinical record review, staff interviews, observations, and facility documentation, staff interviews and policy review, the facility failed to ensure that one staff member had the required qualified food handlers card. The deficient practice could result in deficient practices related to the competency of food service staff.
August 10, 2024Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of two residents (#12 and #23) to be free from sexual abuse by another resident (#45). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. The census was 43.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure allegations of sexual abuse for two residents (#23 and #12) by another resident (#45) was reported immediately to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. The deficient practice could result in the potential harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 43.
May 31, 2024Standard inspection, Complaint inspection · 5 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteFindings include: On May 29, 2024 at 11:08 AM a list of resident names with indwelling devices, wounds, and multi-drug-resistant organisms (MDRO) was requested. The list was reviewed and revealed the following number of residents in the facility within each category: indwelling devices: 4 residents; MDRO: 2 residents. Moreover, the list of residents with wounds that was provided included 21 residents. On May 29, 2024 at 8:50-8:55 AM, an observation of the facility rooms, consisting of hallway rooms 8100-8124 revealed no PPE or enhanced barrier signage present at any resident room. An interview was conducted on May 29, 2024 at 09:56 AM with Certified Nursing Assistant (CNA/Staff # 80) who stated that communication regarding the personal protective equipment (PPE) that needs to be worn is through the signage posted outside a resident' room. [...]
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP). The deficient practice could result in improper infection prevention practices in the facility.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#150 and #56) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in inadequate care of residents.
- 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 clinical record reviews, staff and resident interviews, and policies and procedures, the facility failed to ensure that advance directives were accurate for one resident (#9). The deficient practice could result in residents' wishes not being honored.
- 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 observations, clinical record review, staff interviews and policy review, the facility failed to ensure care plan was revised for one resident (#53).
February 2, 2023Standard inspection · 3 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of records, staff interviews and review of policies and procedures, the facility failed to ensure that two residents (#24, #14) were provided care and services that met professional standards of quality resulting in the residents receiving medications/supplements that were not ordered by the physician. The facility census was 52 residents, and the sample was 18. The deficient practice has the potential for the resident not receiving the appropriate treatment.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during wound treatment for one resident (#32) per professional standards of practice. Resident #32 admitted on [DATE] with diagnoses that included dementia, psychotic disturbance, alzheimer's disease, and pressure ulcer of sacral region, stage 4. Review of a care plan dated September 24, 2021 revealed the resident had a stage 4 pressure injury to sacrum. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed a Staff Assessment for Mental Status score of 3, which indicated severe impairment. Further review revealed the resident had one unhealed stage 4 pressure ulcer. Review of a physician orders revealed: -Dated January 26, 2023 treatment to sacral wound apply collagen sheet and cover with sacral foam dressing. [...]
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and policy, the facility failed to ensure food items were food product were discarded on or before the expiration date in accordance with professional standards.
Fire safety inspections
6 fire safety citations on file: 1 on June 13, 2025, 2 on May 31, 2024, 3 on February 2, 2023.
Every fire safety citation6 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · May 31, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 31, 2024 · 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 · February 2, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 2, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 2, 2023 · Corrected (the home has a date of correction)