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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
0B
0C
May 15, 2025Standard inspection · 4 citations
- 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 and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 3 out of 22 sampled residents, five opened insulin injector pens were not labeled with open dates or a discard date, and they were in the medication cart available for resident use. Resident identifiers: 104, 107, and 109.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 22 sampled residents, a resident taking an anticoagulant medication received two doses in error on one day. Resident identifier: 109.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 22 sampled residents, a resident had a basic metabolic panel (BMP) and complete blood count (CBC) collected without a physician's order. Resident identifier: 15.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, for 1 out of 22 sampled residents, a nurse did not perform hand hygiene, assisted a pill with their bare finger from the medication bottle to the medication cup, and administered the medications to a resident. Resident identifier: 97.
June 29, 2023Standard inspection · 4 citations
- 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 interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician and notify when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the resident had elevated blood sugar levels while waiting for the arrival of their insulin pen and the physician was not notified. Resident identifier 77.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident with elevated Blood Glucose (BG) levels did not receive their insulin injection for 4 days after admission. Additionally, the same resident experienced constipation and did not have the bowel protocol orders administered per the standing orders for constipation. Resident identifier 77.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, medications were not administered to a resident due to being unavailable. Resident identifier 15.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined that for 1 of 23 sampled residents the facility did not ensure that its residents were free of any significant medication errors. Specifically, a resident was given an opioid in conjunction with a medication which had orders to not administer with an opioid. Resident identifier: 181.
September 29, 2021Standard inspection · 0 citations
Fire safety inspections
6 fire safety citations on file: 4 on May 15, 2025, 1 on June 29, 2023, 1 on September 29, 2021.
Every fire safety citation6 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 15, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 15, 2025 · 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 · June 29, 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 · September 29, 2021 · Corrected (the home has a date of correction)