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
0G
0H
0I
Potential for more than minimal harm
19D
4E
0F
Potential for minimal harm
0A
0B
0C
June 3, 2026Standard inspection, Complaint inspection · 9 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide Resident #17 had a dignified existence that included transportation to outpatient appointments.
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on observations and interviews, the facility failed to provide reasonable access for phone communication for one (Resident # 28) out of eight residents sampled.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility did not ensure Level 2 Preadmission Screening and Resident Review (PASRR) evaluation was submitted for one (Resident 88) out of five residents reviewed.
- 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 wroteBased on interview, observation, and record review, the facility did not review and revise the comprehensive care plan related to communication for one (Resident #49) of five residents reviewed for care plans.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews and record review, the facility failed to provide bedfast and residents who prefer to be in their room receive activities to meet the interests and support the physical, mental and psychosocial well-being for one (Resident #82) of two resident reviewed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews, observations, and record review the facility failed to ensure timely care and physician notification related to a skin condition change for one (Resident #82) out of one resident sampled; and failed to provide medications as ordered for one (Resident #96) out of eight residents sampled.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that nebulizer supplies was stored according to professional standards for one (Resident #28) out of eight residents sampled.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and four errors were identified for two (Resident #4, and 23) out of six residents observed. These errors constituted a 12.5% medication error rate.
- D
Have a Compliance and Ethics Program.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure accurate documentation related to medication administration for two Residents (#28, #96) out of eight residents sampled.
November 5, 2024Complaint inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to provide care and treatments in accordance with professional standards of practices as evidence by the lack of documentation of blood pressures prior to the administration of blood pressure medication for two (#3 and #7) of seven residents sampled, failed to document the blood sugars as ordered by the physician for two (#5, and #8) of three sampled residents for monitoring of blood sugar levels, and failed to administer medications as ordered for two diabetic residents (#4 and #10) out of three residents reviewed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure one (#7) out of two residents received Dialysis as scheduled per physician orders, failed to arrange transportation to an alternate site during a period of evacuation, failed to notify the Healthcare Proxy and physician of missed Dialysis treatments, failed to coordinate treatments with the Dialysis center resulting in a wellness check by law enforcement.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure the accounting of narcotic medications were accurately documented for one (#7) of two residents.
January 11, 2024Standard inspection, Complaint inspection · 8 citations
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observations, interviews, and record review, the facility failed to confirm the accuracy and make corrections to the Pre-admission Screening and Resident Review (PASRR) for seven residents (#6, #26, #44, #55, #68, #50, and #28) out of thirty-five residents sampled when mental illness or suspected mental illness diagnoses were identified and/or added to the resident's medical diagnoses.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and eleven errors were identified for three residents (#3, #42, and #76) of seven residents observed. These errors constituted a 34.38% medication error rate.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two residents (#42 and #69) were assessed for the self-administration of medications out of 35 sampled residents.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interviews and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record for one resident (#68) of one resident sampled.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two of two Minimum Data Set (MDS) assessments were accurate to include an active diagnosis of trauma/Post Traumatic Stress Disorder (PTSD), for one resident (#5) of four sampled residents diagnosed with long standing trauma/PTSD.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure respiratory equipment was stored in a sanitary manner for two residents (#14 and #69) of three residents sampled.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure coordination of services occurred between the facility and hospice for one resident (#68) of one resident sampled for hospice.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record review, the facility 1) failed to change the dressings and maintain midline catheters for two residents (#198 and #17) out of three sampled residents with intravenous access, 2) failed to provide wound care for two residents (#44 and #196) out of five sampled residents for wound care as ordered by the physician.
September 23, 2021Standard inspection · 3 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis services were provided consistent professional standards of practice for one (Resident #75) of one resident receiving Dialysis. Findings Included: During an interview with the Staff C, LPN on 9/22/21, she confirmed the dialysis book was at the nurse's station and she had one [Resident #75] that received dialysis three days a week on Tuesday, Thursday, and Saturday. She opened the dialysis book which was empty and stated that she completed the dialysis form yesterday morning prior to Resident #75 going to dialysis. She said the unit manager took the book last night before she left and Staff C was unaware of where the forms were located. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, staff interview, and medical record review, the facility failed to assess four lower extremity areas/wounds, either during bathing/showers and or weekly skin checks for one (Resident #11) of thirty sampled residents.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide restorative services to ensure that the resident's abilities in activities of daily living did not decline for one ( Resident #47) of two sampled residents.
Fire safety inspections
10 fire safety citations on file: 3 on June 3, 2026, 4 on January 11, 2024, 3 on September 23, 2021.
Every fire safety citation10 citations
- E
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 · June 3, 2026 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · June 3, 2026 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 3, 2026 · 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 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 11, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 11, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 23, 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 · September 23, 2021 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · September 23, 2021 · Corrected (the home has a date of correction)