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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
0E
0F
Potential for minimal harm
0A
0B
0C
June 12, 2025Standard inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure quality of care by not following physicians' orders for 3 residents (#13, #133, and #29) of 3 residents reviewed for following physician's orders.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate medical records for 2 residents (#13 and #133) of 3 residents reviewed for accuracy of medical records.
January 13, 2025Complaint inspection · 1 citation
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on staff interview, resident interview, observations and resident medical record review, it was determined that the facility failed to ensure the residents' right to call light access for two residents (Resident #3 and Resident #4) out of eight residents observed during the survey.
January 5, 2024Standard inspection · 1 citation
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on clinical record review, and staff interview, the facility failed to ensure 1 (Resident #30) of 1 sampled resident with admitting diagnoses of serious mental illness had a complete and accurate Preadmission Screening and Resident Review (PASRR).
March 17, 2022Standard inspection · 6 citations
- 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 medical record review, review of facility's policies and procedure, staff, and resident interviews the facility failed to ensure 3 (Residents #4, #5 and #13) of 16 residents reviewed for advance directive were informed and provided written information of advance directive rights and ensure their advance directive wishes were followed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan containing interventions to address the cardiac pacemaker for 1 (Resident #26) of 2 residents reviewed for cardiac pacemaker.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review and resident and staff interview, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 1 (Resident #5) of 1 reviewed for showers.
- 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 clinical record review and staff interviews, the facility failed to maintain documentation of rationale to justify an increase in psychotropic medication (medication that affects a person's mental state) for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications. This has the potential to lead to the administration of unnecessary medications.
- D
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, staff and resident interviews, and medication record review, the facility failed to identify and monitor the safe and proper storage of medications for 2 (Resident #191 and Resident #13) of 2 residents reviewed for medication storage.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interviews the facility failed to ensure infection control measures were maintained during medication administration for 2 residents (Resident #13 and Resident #141) of 3 reviewed for medication administration and infection control.
Fire safety inspections
5 fire safety citations on file: 1 on June 12, 2025, 4 on January 5, 2024.
Every fire safety citation5 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 5, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · January 5, 2024 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · January 5, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 5, 2024 · Corrected (the home has a date of correction)