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
April 2, 2025Standard inspection · 6 citations
- 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 observation, record review, and interview, the facility failed to ensure care plans were implemented and/or updated for 1 of 15 resident care plans reviewed. (Resident 43)
- 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 ensure residents received necessary care and services, related to lack of monitoring of sleep patterns per the care plan for 1 of 1 resident reviewed for care planning. (Resident 22)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure indwelling Foley (urinary) catheter tubing was kept off of the floor for a resident with a history of urinary tract infections (UTIs) for 1 of 1 resident reviewed for urinary catheters. (Resident 46)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to ensure timely follow up on dietary recommendations was completed for a resident with a history of weight loss for 1 of 3 residents reviewed for nutrition. (Resident 38)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to the lack of documentation prior to a urinalysis being completed on a resident for 1 of 1 resident reviewed for UTIs (urinary tract infections). (Resident 9)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not changing gloves and performing hand hygiene during a wound treatment for 1 of 2 residents reviewed for pressure ulcers. (Resident 14)
June 28, 2024Standard inspection · 3 citations
- 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 record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for pain for 1 of 16 resident care plans reviewed. (Residents 21 and 20)
- 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 observation, record review and interview, the facility failed to ensure care plans were implemented and/ or updated with changes for 3 of 16 resident care plans reviewed. (Residents 44, 21, and 32)
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities were implemented for a cognitively impaired dependent resident for 1 of 1 residents reviewed for activities. (Resident 4)
September 8, 2023Standard inspection · 1 citation
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 residents reviewed for intravenous care. (Resident 148)
Fire safety inspections
8 fire safety citations on file: 5 on April 2, 2025, 2 on June 28, 2024, 1 on September 8, 2023.
Every fire safety citation8 citations
- E
Meet other general requirements.
K 100 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Have horizontal exits used in accordance with safety requirements.
K 226 · April 2, 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 2, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 2, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 28, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 28, 2024 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · September 8, 2023 · Corrected (the home has a date of correction)