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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
0E
0F
Potential for minimal harm
0A
0B
0C
November 19, 2025Standard inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the physician and the physician was notified when the medications were not administered for 1 of 5 residents reviewed for quality of care. (Resident 3)
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccines were provided when requested with a signed consent form for 1 of 5 residents reviewed for immunizations. (Resident 3)
November 4, 2024Standard inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for 1 of 1 resident reviewed for MDS accuracy. (Resident 28)
- 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 ensure a comprehensive person-centered care plan was developed for a resident identified as a high risk for elopement for 1 of 6 residents reviewed for accidents. (Resident 4)
- 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 wrote2. During an observation of the medication cart on the 300-unit, on 10/30/24 at 11:09 a.m., the eye drops for Residents 4, 56 and 61 had no open dates on the outside container or the bottle containing the eye drops. a. The clinical record for Resident 4 was reviewed on 10/29/24 at 4:10 p.m. The diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (a type of dementia), diabetic kidney disease, and long-term use of insulin. A physician's order, dated 10/3/24, indicated to instill Systane ophthalmic solution (for dry eyes) into both eyes. b. The clinical record for Resident 56 was reviewed on 10/29/24 at 4:27 p.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), cachexia (weakness or wasting of the body), anorexia, Alzheimer's disease, and dementia without behavioral psychotic or mood disturbance. [...]
September 13, 2023Standard inspection · 3 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wrote3. The record for Resident 20 was reviewed on 9/11/23 at 10:40 a.m. Diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes, Alzheimer's disease, and dementia. The residents weight log indicated the following weights: 1. On 4/3/23, the weight was 190.3 lbs. 2. On 4/10/23, the weight was 188.0 lbs. 3. On 4/17/23, the weight was 170.4 lbs. The resident had a 9.36% weight loss in 1 week. A care plan, dated 5/18/23, indicated the facility will weigh the resident each Monday. A care plan, dated 8/17/23, indicated to notify the MD (medical doctor) of any condition changes. During an interview, on 9/12/23 at 11:48 a.m., the DON (Director of Nursing) indicated the facility had not contacted the MD about the resident's weight changes until 4/26/23. The MD was not notified about the weight loss until 9 days later. [...]
- D
Ensure a qualified health professional conducts resident assessments.
Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS (Minimum Data Set) quarterly review was correctly filled out regarding the PASARR (Preadmission Screening and Resident Review) for 1 of 1 resident reviewed for resident assessment. (Resident 7)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to recognize a significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 45)
Fire safety inspections
5 fire safety citations on file: 2 on November 19, 2025, 2 on November 4, 2024, 1 on September 13, 2023.
Every fire safety citation5 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 19, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 19, 2025 · Corrected (the home has a date of correction)
- 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 · November 4, 2024 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · November 4, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 13, 2023 · Corrected (the home has a date of correction)