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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
18D
3E
5F
Potential for minimal harm
0A
0B
0C
July 28, 2026Standard inspection, Complaint inspection · 7 citations
- F
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 observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 31 residents who resided in the facility and received their meals from the kitchen.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff failed to secure chemicals safely from access by the seven cognitively impaired, independently mobile residents who resided in the facility's memory care unit.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications and biologicals adequately when staff failed to discard expired stock medication from the emergency kit.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, interview, and observation, the facility failed to provide care for Resident (R)7 in a manner that protected and promoted their dignity.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to notify Resident (R) 36's family when R36 had a change in condition.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included unsuccessful attempts at nonpharmacological symptom management and risk versus benefits for the continued use for Resident (R)29's and R12's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Resident (R) 6 and/or their representatives with a written notification of transfer for facility-initiated transfers and a bed hold policy upon transfer to the hospital. The facility further failed to notify the long-term care ombudsman (LTCO) of transfers to the hospital.
September 18, 2024Standard inspection · 8 citations
- F
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 wroteThe facility had a census of 31 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for the 31 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteThe facility had a census of 31 residents. Based on observation, interview, and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control. This placed the 31 residents in the facility at risk for lack of identification and treatment of infections.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with five reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer and administer or obtain an informed declination, or a physician-documented contraindication for Resident (R)3, R6, R20, R21, and R22, pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents of which two were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure pressure-reducing devices functioned correctly to prevent the worsening of pressure ulcer/injury for Resident (R) 20's coccyx (area at the base of the spine) wound. This placed the resident at risk for delayed healing or worsening of an existing pressure ulcer.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that staff failed to follow the physician's orders to administer insulin (controls the amount of sugar in the blood by moving into cells) and medications to treat Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). This placed the resident at risk for physical decline and an ineffective medication regimen.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to administer medication as ordered by the physician for one resident, Resident (R) 2, who received insulin (controls the amount of sugar in the blood by moving into the cells) and medications to treat Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). This placed the resident at risk for unnecessary medication side effects and an ineffective medication regimen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were used for Resident (R) 20 who had an ongoing pressure ulcer and dressing change. The deficient practice placed the resident at risk of infectious disease processes.
February 26, 2024Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThe facility identified a census of 34 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, observation, and interview, the facility failed to implement interventions to prevent a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer to Resident (R) 1's left buttock and then failed to provide routine treatment and nutritional interventions to promote healing of R1's pressure ulcer. This deficient practice placed R1 at risk for pressure ulcer development, pain, infection, and complications from delayed healing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility identified a census of 34 residents with three residents reviewed for care and treatment of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 received treatment and care in accordance with professional standards of practice related to CHF. This deficient practice placed R2 at risk for complications from congestive heart failure that included weight gain, edema (swelling), and difficulty breathing.
January 31, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility identified a census of 33. The sample included three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and supervision). Based on observation, record review, and interviews, the facility failed to ensure interventions used to prevent elopement (window alarms) were functional and tamper-resistant. The facility further failed to accurately assess and identify Resident (R)1's elopement risk. R1 was cognitively impaired, lived on a secured memory unit, and had a history of wandering; though, the latest elopement assessment performed on 01/08/24 indicated the resident had no wandering and was at low risk for elopement. On 01/24/24 at approximately 12:05 PM R1 moved her couch and a table away from her window, opened the window and screen, and exited the facility via the window. [...]
October 10, 2023Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteThe facility identified a census of 31 residents with three residents reviewed for resident rights. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1's right to dignity. This deficient practice placed R1 at risk for impaired psychosocial wellbeing.
March 28, 2023Standard inspection · 10 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents, with four reviewed for falls. Based on observation, record review, and interview, the facility failed to implement the care planned interventions for Resident (R) 3, who had multiple falls related to inappropriate footwear, with one fall resulting in rib fractures (broken bones). The facility further failed to identify and implement interventions to prevent falls for R5, who had multiple falls. This placed the resident at risk for further falls and avoidable injury.
- F
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 wroteThe facility had a census 30 residents. Based on record review and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week placing all resident who reside in the facility at risk of lack of assessments and inappropriate care.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to report to the state agency an unwitnessed fall which resulted in a fracture for Resident (R) 3, and an injury of unknown origin for R5, who had a laceration over her left eye. This placed the residents at risk for further injury and unidentified abuse or mistreatment.
- D
Respond appropriately to all alleged violations.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate an injury of unknown origin for one sampled resident, Resident (R) 5, who had a laceration over her left eye. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings Included: - The Electronic Medical Record (EMR) documented R5 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), epilepsy (brain disorder characterized by repeated seizures), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). [...]
- 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 wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered interventions for inappropriate sexual behavior for one sample resident, Resident (R) 2, and failed to revise and implement person- centered interventions to prevent falls for R3 and R5, who had multiple falls. This placed the resident at risk for uncommunicated and/or unmet care needs. Findings Included: [...]
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge plan to support and accommodate Resident (R) 29's goal of returning to the community. This placed R29 at risk for unmet care needs.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge summary for one resident reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for Resident (R) 29. This placed the resident at risk for unmet care needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents, with eight reviewed for behaviors. Based on observation, record review, and interview, the facility failed to consistently monitor Resident (R) 3, who had a physician order for hourly suicide checks. This placed the resident at risk for self-injury and death.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteThe facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three sampled residents, Resident (R) 2, who had inappropriate sexual behaviors; R3, who had stated she wanted to harm herself twice in the last six months; and R5, who had behaviors. This placed the residents at risk for further decline of their emotional and mental well-being
- D
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 wroteThe facility had a census of 30 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)5's as needed (PRN) lorazepam (antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic (altering mood and mind) medication use.
Fire safety inspections
23 fire safety citations on file: 1 on September 18, 2024, 6 on March 28, 2023, 16 on September 8, 2021.
Every fire safety citation23 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · September 18, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · March 28, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · March 28, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · September 8, 2021 · 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 · September 8, 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 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · September 8, 2021 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · September 8, 2021 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 8, 2021 · Corrected (the home has a date of correction)