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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
0E
0F
Potential for minimal harm
0A
0B
0C
April 24, 2025Standard inspection · 7 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of three residents (R4, R27) reviewed for PASARR screening, in the sample of 24.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) Level II screening was completed for one of three residents (R31) reviewed for PASARR screenings in the sample of 24.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a pressure ulcer treatment was completed as ordered for one of two residents (R31) reviewed for pressure ulcers in the sample of 24.
- 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 wroteBased on interview, observation and record review, the facility failed to ensure a range of motion program was implemented for a resident with functional limitations for one of four residents (R31) reviewed for range of motion in the sample of 24.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure tubing for an enteral tube feeding was dated, and items utilized during a tube feeding remained clean for one of two residents (R1) reviewed for tube feedings in the sample of 24.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on interview and record review the facility failed to implement specific PTSD/Post Traumatic Stress Disorder interventions for one of one (R27) residents reviewed for Post Traumatic Stress Disorder in a sample of 24.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented prior to administering cares for two of eight residents (R31 and R41) reviewed for Transmission Based Precautions in the sample of 24.
March 8, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on Interview and Record review, the facility failed to prevent an incident of resident to resident physical abuse, re-assess resident's risk for abuse and revise abuse care plans after founded physical abuse occurred for two of three residents (R1, R2) reviewed for abuse in the sample of three.
May 23, 2024Standard inspection · 3 citations
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to identify the indication for the prolonged duration of use for 1 of 1 (R22) resident with a prescribed antibiotic maintenance dose in a sample of 12 residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R4, R27 and R31) on the sample of 10 residents reviewed for medication pass. This failure resulted in four medication errors out of thirty- one opportunities for error, for a 21.9% medication error rate.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to identify, track, monitor and analyze for trends in data for 2 of 2 (R3, R22) in a sample of 12 residents.
March 17, 2023Standard inspection · 1 citation
- 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 wroteBased on observation, interview and record review the facility failed to identify an appropriate indication for administration of an antipsychotic medication for two residents with a diagnosis of Dementia (R31, R42) of three residents reviewed for unnecessary antipsychotic medications in the sample of 18.
Fire safety inspections
11 fire safety citations on file: 3 on April 24, 2025, 2 on May 23, 2024, 6 on March 17, 2023.
Every fire safety citation11 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · April 24, 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 · April 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 17, 2023 · 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 · March 17, 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 17, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 17, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 17, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 17, 2023 · Corrected (the home has a date of correction)