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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
16D
3E
3F
Potential for minimal harm
0A
0B
0C
February 6, 2025Standard inspection · 16 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 wroteThe facility identified a census of 72 residents. The sample included 13 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 72 residents residing in the facility. Findings Included: - On 02/05/25, Administrative Nurse D provided a Facility Assessment updated 08/08/24. A review of the facility assessment revealed the following: The facility assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility identified a census of 47 residents. The facility identified three residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure used face masks were stored or disposed of in a sanitary manner, the facility further failed to ensure all oxygen cannulas were stored in a sanitary manner and further failed to ensure a Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) program specific to the facility was put in place. These deficient practices placed the residents at risk for infectious diseases.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with one medication room and four medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This placed the residents at risk for misappropriation and/or diversion of controlled substances.
- 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 wroteThe facility reported a census of 72 residents. Based on observations, record reviews, and interviews, the facility failed to ensure safe medication storage of one of its four medication carts. This deficient practice placed the resident at risk for diversion and ineffective medication regimen. Findings Included: - On 02/04/25 at 07:01 AM, an inspection of the 100 Hall revealed an unsecured treatment cart outside of Resident (R) 21's. R21's door was closed. No staff were present in the hallway to monitor the cart. An inspection of the cart revealed medications and wound care supplies for R21 in the top drawer. On 02/04/25 at 07:05 AM, Administration Nurse E walked down the hall and verified that the cart was left unlocked. She stated staff were expected to lock the cart. Administrative Nurse E secured the cart. [...]
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 1, R12, R27, and R28. This placed the residents at increased risk for complications related to pneumonia.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R) 44. This deficient practice placed R44 at risk of delayed care or uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). [...]
- 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 reported a census of 72 residents. The sample included 12 with 12 residents reviewed for care plan revisions. Based on observations, interviews, and record review, the facility failed to revise Resident (R)12's care plan to reflect her current transfer requirements. The facility additionally failed to revise R23's hospice care planned interventions. These deficient practices placed the residents at risk for impaired care due to uncommunicated care needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility identified a census of 72 residents. The sample included 13 residents with one reviewed for quality of care. Based on interviews, observations, and record review, the facility failed to evaluate Resident (R)27's risks and abilities related to handling hot liquids. This deficient practice placed R27 at risk for preventable accidents and injuries.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with three residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 38 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R38 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension).
- D
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 72 residents, the sample included 13 with two reviewed for accidents. Based on interviews, record review, and observations, the facility failed to ensure Resident (R)16's safety related to following her care-planned fall interventions. This deficient practice placed R16 at risk for preventable falls and injuries. - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) noted diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and orthostatic hypotension (blood pressure dropping with change of position). [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with two reviewed for nutrition. Based on observation, record review, and interviews the facility failed to identify and implement nutritional interventions related to Resident (R) 26'scontinued weight loss. This deficient practice placed R26 at risk for malnourishment-related complications.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 23 had a physician order for hemodialysis that included an indication. The facility also failed to follow a physician's order for fluid restriction for R23. These deficient practices placed her at risk of adverse outcomes and physical complications related to dialysis.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteThe facility identified a census of 47. The sample included 13 residents with four residents reviewed for dementia care. Based on observation, record review, and interviews, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address R13's dementia (a progressive mental disorder characterized by failing memory, and confusion) diagnosis which included the need for close supervision to prevent the resident from wandering and falls. This deficient practice placed R13 at risk of ineffective treatment and decreased quality of care.
- 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 reported a census of 72 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure the Consulting Pharmacist (CP) identified and made recommendations related to Resident (R) 12's Midodrine (medication used to raise low blood pressure) medication. This placed R12 at risk for unnecessary medications and potential side effects.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility reported a census of 72 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure safe medication administration for Resident (R)12's Midodrine (medication used to raise low blood pressure) medication. This placed R12 at risk for unnecessary medications and potential side effects.
- 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 identified a census of 47 residents. The sample included 13 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication or a documented physician rationale for antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and a gradual dose reduction was not attempted for Resident (R) 26. The facility also failed to ensure R1 had physician rationale for continued use of as-needed psychotropic (alters mood or thought) medications for an extended period beyond 14 days. These deficient practices placed the residents at risk for adverse medication effects and unnecessary medications.
August 26, 2024Complaint inspection · 2 citations
- 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 reported a census of 40 residents, with three residents sampled. Based on observation, interview, and record review the facility failed to revise Resident (R)1's care plan to reflect interventions related to R1's personal hygiene.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteThe facility reported a census of 40 residents, with three residents sampled. Based on observation, interview, and record review the facility failed to ensure staff provided Resident (R)1 the necessary bathing services to maintain good grooming and personal hygiene.
April 19, 2023Standard inspection · 5 citations
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility reported a census of 43 residents with 14 residents sampled, including one resident reviewed for hydration. Based on observation, interview, and record review, the facility failed to provide adequate hydration for dependent resident R99, who was observed with dry lips and mouth, deep grooves in her tongue, an empty water cup, water out of reach of the resident, several staff provided cares but did not offer water, R99 cried and moaned asking for water, and her EMR recorded she received only two to four cups of water daily from 04/12/23-04/18/23.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 43 residents with 14 residents sampled including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safe ambulation with planned interventions for one Resident (R)34, while ambulating to the bathroom, to prevent accidents.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteThe facility reported a census of 43 residents with 14 residents sampled, including one resident reviewed for pain. Based on observation, interview, and record review, the facility failed to ensure appropriate pain control for the one Resident (R)99, by not ensuring the resident swallowed the pain medication.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility reported a census of 43 residents. The sample included 14 residents, with five reviewed for immunizations. The facility failed to provide proof of vaccination or declination of vaccines for the 2022-2023 influenza or pneumococcal (vaccines designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) for three of the five residents reviewed.
November 18, 2021Standard inspection · 0 citations
Fire safety inspections
45 fire safety citations on file: 10 on February 6, 2025, 13 on April 19, 2023, 22 on November 18, 2021.
Every fire safety citation45 citations
- F
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
K 132 · February 6, 2025 · 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 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · February 6, 2025 · 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 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 6, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · April 19, 2023 · 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 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 19, 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 19, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · April 19, 2023 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 19, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 19, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 19, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 19, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 19, 2023 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · November 18, 2021 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · November 18, 2021 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · November 18, 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 · November 18, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 18, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · November 18, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 18, 2021 · 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 · November 18, 2021 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 18, 2021 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · November 18, 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 · November 18, 2021 · 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 18, 2021 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 18, 2021 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 18, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 18, 2021 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · November 18, 2021 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 18, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 18, 2021 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · November 18, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · November 18, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 18, 2021 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · November 18, 2021 · Corrected (the home has a date of correction)