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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
0E
0F
Potential for minimal harm
0A
0B
0C
June 20, 2025Standard inspection, Complaint inspection · 8 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 staff interviews and record review, the facility failed to protect four of four male residents (R) (R127, R12, R105, and R106) right to be free from sexual abuse by R147. Specifically, the facility failed to protect R127, R12, R105, and R106 from R147s' known inappropriate hypersexual behaviors.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy titled, Restraints, the facility failed to ensure one of one Resident (R) (R102) reviewed for physical restraints was not physically restrained by being in bed with a Geri-chair and a regular chair placed up against her bed, blocking her ability to get out of her bed on one side.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition-Reporting and Investigating, the facility failed to report allegations of sexual abuse for two of four male residents (R) (R106, and R107) reviewed for abuse related to R147's inappropriate hypersexual behaviors.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interviews and record review, and review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, the facility failed to investigate allegations of abuse for two of four male residents (R) (R106, and R107) related to R147's known inappropriate hypersexual behaviors. The facility failed to identify and investigate allegations of resident-to-resident sexual abuse after resident R147 was observed in R106's room and sitting on R106's lap and then stroking and rubbing R105's face. This failure had the potential for additional male residents to be sexually abused by R147.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Fall Management, the facility failed to properly assess one of four Residents (R) (R45) for the use of a Geri-chair. The use of a Geri-chair without a proper therapy assessment created the potential for R45 to sustain falls with potential injuries.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interviews and document review, the facility failed to ensure one of one Resident (R) (R1) urinalysis was completed timely. This had the potential to delay the resident's treatment of abnormal laboratory results.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and review of facility policies titled, Personal Hygiene, the facility failed to properly don (put on) a hair restraint while working in one of three kitchenettes (an area in which the food was served). This had the potential to increase the risk of foodborne illnesses that would affect 54 residents receiving an oral diet.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review, review of the facility policy titled, Transmission-Based Precautions, and Centers for Disease Control (CDC) guidance, the facility failed to adhere to infection control practices and policies for one of two residents Resident (R) (R130). Specifically, the facility failed to ensure staff wore a gown for a resident on Enhanced Barrier Precautions while bathing and during wound care. The deficient practice increased the risk for cross contamination and infections.
November 7, 2024Complaint inspection · 1 citation
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview, record review, and review of the facility's policy titled, Laboratory, Radiological, and other Diagnostic Services, the facility failed to ensure that laboratory tests were obtained as ordered by the physician, for one of 13 sampled residents (R) (R1).
July 11, 2024Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and review of the facility's Wound Care manual, the facility failed to ensure that pressure ulcers were thoroughly and routinely assessed for two of 10 residents (R) (R8 and R9).
August 10, 2023Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, staff interviews, and review of facility policies titled, Skilled Nursing Services Handwashing and Pharmacy Services Oral Inhalation and Nebulizer Administration, the facility failed to maintain infection control standard precautions by not performing proper hand hygiene during administration of eye drops, not cleaning the mouthpiece of inhalers after administration, and not properly disinfecting a basket used for medication administration. The deficient practice had the probability to increase the potential for residents to contract an infectious disease.
December 17, 2021Standard inspection · 0 citations
Fire safety inspections
5 fire safety citations on file: 4 on June 20, 2025, 1 on August 10, 2023.
Every fire safety citation5 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 20, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 20, 2025 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 20, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · June 20, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 10, 2023 · Corrected (the home has a date of correction)