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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
1E
1F
Potential for minimal harm
0A
0B
1C
March 5, 2026Standard inspection · 8 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff hired in the position of Dietary Manager had obtained the required qualifications to serve as Dietary Manager of the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents Minimum Data Set (MDS) assessments were accurate for 1 of 3 residents reviewed for behavioral health (Resident #131).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to coordinate Preadmission Screening and Resident Review (PASRR) for the residents with newly evident or possible serious mental disorder for 3 of 7 residents reviewed for PASRR (Residents #7, #10, and #131).
- 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 staff dated the wound dressing for 1 of 2 residents reviewed for skin integrity (Resident #15), failed to ensure physician-ordered weights were obtained for 1 of 6 residents reviewed for medication management (Resident #15), and failed to ensure staff followed physician-ordered parameters for administering blood glucose medications for 1 of 6 residents reviewed for medication management (Resident #66).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to monitor weights for residents who were at nutritional risk for 2 of 4 residents reviewed for weight loss (Residents #63 and #88).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received oxygen as ordered by physician for 1 of 4 residents reviewed for oxygen therapy (Resident #106).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to ensure a PRN (as needed) psychotropic medication order had limit in duration and was clinically appropriate for 1 of 5 residents reviewed for unnecessary medications (Resident #10).
- 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, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles in 2 of 4 units.
December 2, 2024Complaint inspection · 1 citation
- 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 medications as ordered by physician for 1 of 3 residents reviewed, Resident #2.
September 6, 2024Standard inspection · 6 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of the minimum data set for 1 of 4 residents reviewed for skin conditions, Resident #106.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were diagnosed with possible serious mental disorder were referred for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 3 residents reviewed for PASARR, Resident #38.
- 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 residents received care and services in accordance with professional standards of practice for PICC (Peripherally Inserted Central Catheter) access devices for 2 of 6 residents reviewed with a central venous access device (CVAD), Resident #212 and Resident #215, and for 1 of 3 residents reviewed for pain management, Resident #92.
- 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 wrote6) During an observation on 9/3/2024 at 9:35 AM, there were three pills in a medication cup on the bedside table in Resident #75's room. During an interview on 9/3/2024 at 9:35 AM, Resident #75 stated, It is aspirin, my probiotic and iron pill. I cannot take it on an empty stomach, so I take it after breakfast. During an interview on 9/5/2024 at 8:43 AM, with the Director of Nursing stated, Medication should not be at resident's bedside. Residents need an order for self administration of medication and an assessment of their capability. Medication would need to be stored in the first drawer which has a lock to secure medication kept in the resident's room. Review of the facility policy and procedure titled Medication Storage with the last review date of 1/11/2024 read, Policy: [...]
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the walk-in and reach-in coolers in the areas of the main and satellite kitchens.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used personal protective equipment (PPE) while providing services to 1 of 3 residents reviewed for isolation precautions, Resident #96, to prevent the possible spread of infection and communicable disease.
May 4, 2023Standard inspection · 3 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, interview, and record review, the facility failed to ensure medications were securely stored in 3 of 4 Halls in the rooms of Resident #41, Resident #55, Resident #324, and Resident #164 (Photographic evidence obtained).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 7 residents reviewed for oxygen administration, Residents #62, #68, and #265 (Photographic evidence obtained).
- C
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreements provided for the selection of a venue convenient to both parties for 3 of 3 reviewed residents, Residents #114, #115 and #166.
Fire safety inspections
2 fire safety citations on file: 1 on March 5, 2026, 1 on May 4, 2023.
Every fire safety citation2 citations
- 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 · March 5, 2026 · Corrected (the home has a date of correction)
- F
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 · May 4, 2023 · Corrected (the home has a date of correction)