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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
1E
0F
Potential for minimal harm
0A
0B
0C
August 11, 2025Standard inspection · 4 citations
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had effective pain management for 1 of 2 residents reviewed for pain management (Resident 43).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to administer medication according to physician orders and held medications without a physician order for 1 of 5 residents reviewed for unnecessary medications (Resident 6).
- 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, record review, and interview, the facility failed to ensure a medication prescription label matched the physician's order for 1 of 35 medication administrations observed (Resident 28).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure an influenza vaccination was offered or administered to 1 of 5 residents reviewed for immunizations (Resident 1).
June 10, 2025Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a physician ordered medication was administered and documented appropriately for 1 of 3 residents reviewed for quality of care. (Resident B)
August 16, 2024Standard inspection · 4 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a self-administration assessment had been completed for a resident who was observed to self-administer her medications for 1 or 1 random observation (Resident 15).
- 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 interviews and record reviews, the facility failed to ensure care plan meetings were completed timely for 2 of 24 residents reviewed for care plan meetings (Residents 12 and 24).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Qualified Medication Aide (QMA) followed proper standards of practice for 1 of 1 residents reviewed for pressure ulcer care (Resident 218).
- 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 medication storage areas were free from personal drinks, and failed to ensure expired medication was disposed of (Resident 38) for 2 of 4 medication carts reviewed for medication storage.
June 6, 2023Standard inspection · 6 citations
- E
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 proper food handling for 1 of 2 dining observations and failed to ensure proper handwashing for 3 of 3 dining observations.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were addressed in a dignified manner for 3 of 3 residents reviewed for dignity (Residents 18, 30, and 10). Findings Include: 1. During the lunch meal observation, on 5/30/23 at 12:20 p.m., Resident 18 was sitting at the lunch table and was being assisted with eating by Activity Assistant 5. Activity Assistant 5 addressed Resident 18 as Mama. She asked Resident 18, Mama, would you like to take a bite? Activity Assistant 5 proceeded to assist the Resident 18 with eating and asked, Mama, would you like to take a drink? Resident 18's record was reviewed on 6/1/23 at 10:00 a.m. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Activities of Daily Living (ADL, activities related to personal care) were completed for 4 of 24 residents reviewed for ADL care (Residents 57, 15, 34, and 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 document, report, and address a skin condition on a resident for 1 of 24 residents reviewed for skin conditions (Resident 28).
- 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, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag did not touch the floor and staff failed to follow the proper procedure for changing a urinary drainage leg bag (a urinary drainage device attached to the resident's leg) to a standard urinary drainage bag for 1 of 1 resident reviewed for catheter care (Resident 55).
- 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 pharmacy recommendations were addressed and initiated for 2 of 5 residents reviewed for unnecessary medications (Residents 22 and 25).
Fire safety inspections
5 fire safety citations on file: 3 on August 11, 2025, 1 on August 16, 2024, 1 on June 6, 2023.
Every fire safety citation5 citations
- F
Conduct testing and exercise requirements.
E 39 · August 11, 2025 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · August 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 11, 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 · August 16, 2024 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · June 6, 2023 · Corrected (the home has a date of correction)