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
9D
4E
2F
Potential for minimal harm
0A
0B
0C
May 4, 2025Standard inspection, Complaint inspection · 6 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Preventative Maintenance Program, the facility failed to maintain a safe and sanitary environment in nine rooms on two of two halls (Blue Hall and Red Hall). These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment, and a potential for diminished quality of life.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on resident and staff interviews, record reviews, and review of the facility's policies titled Bed Hold Notice and Transfer and Discharge, the facility failed to ensure one of 25 sampled residents (R) (R24) was provided with a written bed hold notice or reason for transfer at the time of transfer. This failure had the potential to place the residents or resident representative at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility.
- 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, staff interviews, and record reviews, the facility failed to implement care plans for two of 25 sampled residents (R) (R306 and R13). This deficient practice had the potential to place R306 and R13 at risk of medical complications, unmet needs, and a diminished quality of life.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Accident and Supervision, the facility failed to ensure an environment free of accident hazards for three of 25 sampled residents (R) (R21, R25, and R18). This deficient practice had the potential to place R21, R25, and R18 at risk of avoidable accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that the physician's order for oxygen administration was followed for one of 10 residents (R) (R13) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Behavioral Health Services, the facility failed to ensure one of 25 sampled residents (R) (R306) received behavioral health services to address behaviors. The deficient practice had the potential to place R306 at risk for medical complications, unmet needs, and a diminished quality of life.
April 2, 2023Standard inspection · 3 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews, record review, and review of facility policy titled Infection Prevention and Control Program the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection and failed to implement a procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system. The facility census was 52.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interviews, record review, and review of facility policy titled Infection Prevention and Control Program the facility failed to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccine for three residents (R#11, R#6, and R#50) of five sampled residents reviewed for immunizations.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interviews, record reviews, and review of facility policy titled Infection Prevention and Control Program the facility failed to ensure that three residents (R#6, R#11, and R#50) of five sampled residents were offered, received, and had documentation related to the COVID-19 vaccine.
August 26, 2021Standard inspection · 6 citations
- F
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 review of facility policy titled Visitation and Infection Control Policy, the facility failed to designate a qualified infection preventionist who completed specialized training in infection prevention and control. The deficient practice placed all 49 residents at risk for potential transmission of COVID-19 infections and other communicable diseases.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility policy titled Visitation and Infection Control, and staff interviews, the facility failed to ensure that infection control practices were followed and adhered to by facility staff. Specifically, the facility failed to provide Personal Protective Equipment (PPE) for staff use for one resident on observation isolation (room [ROOM NUMBER]) and failed to ensure that infection control practices were followed by staff during meal service on the COVID isolation unit. The deficient practice had the potential to affect 19 residents residing on the Blue Hall within the facility. Total census was 49.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, record review, and resident/staff interviews, the facility failed to allow one of 20 sampled residents (R) (R#31) the choice of when she could take a shower and failed to facilitate that choice in a bathing schedule.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, staff interviews, and review of facility policy titled Detailed Cleaning, the facility failed to ensure that there was a clean and comfortable environment as evidence by stained privacy curtains, over bed lighting not properly affixed to the wall, large brown stains on the floor, holes in closet door, missing tiles in the bathroom, a cracked trash can, and metal door frame in shared bathroom had a piece of protruding metal at the base. These environmental concerns were observed in 12 of 49 resident rooms and/or bathrooms (106, 108, 110, 112, 117, 118, 119, 120, 125, 126, 127, and 128).
- 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 review, review of facility policy titled Care Plans, Comprehensive Person-Centered, and staff interviews, the facility failed to follow the respiratory care plan for one of five residents (R) (#27) who required continuous oxygen.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that a resident received oxygen at the correct flow rate for one of five residents (R) (#27) who required continuous oxygen.
Fire safety inspections
12 fire safety citations on file: 6 on May 4, 2025, 5 on April 2, 2023, 1 on August 26, 2021.
Every fire safety citation12 citations
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 4, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · May 4, 2025 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · May 4, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 4, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 4, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 4, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 2, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 2, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 2, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 2, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 2, 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 · August 26, 2021 · Corrected (the home has a date of correction)