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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
1E
0F
Potential for minimal harm
0A
0B
0C
February 10, 2026Standard inspection · 3 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to ensure one resident (#69) received a nutritious vegetarian diet. This affected one resident (#69) of four residents reviewed for nutrition. The facility census was 93. Findings Include:Review of the medical record for resident #69 revealed an initial admission date of 02/09/17 with the diagnoses including but not limited to moderate protein calorie malnutrition, hypertension, anemia, major depression disorder, osteoarthritis, spinal stenosis, hyperlipidemia, constipation, polyneuropathy and hypothyroidism. Review of the plan of care dated 02/15/17 revealed the resident had the potential for alteration in nutrition and hydration related to at moderate risk for malnutrition, followed a vegetarian diet related to cultural patterns. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to ensure non-pharmacological interventions were provided prior to the administration of as needed pain medications for Resident #5, #1 and #30, this affected three of four residents reviewed for pain management. The facility failed to ensure descriptions of pain were documented for Resident #1 and #30 which affected two of four residents reviewed for pain management. The facility census was 93.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, medical record review, and review of facility policy the facility failed to ensure pain parameters were in place for Resident #1, #30, and #66, who received multiple as needed pain medications. This affected three of four residents reviewed for pain management. The facility census was 93.
January 14, 2025Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, medical record review, review of facility investigation, and review of facility self-reported incidents (SRI's) revealed the facility failed to ensure Resident #59's money was not misappropriated by facility staff. This affected one resident (#59) of three residents reviewed for misappropriation. The facility census was 94.
July 25, 2024Standard inspection · 5 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on interview and observation, the facility failed to ensure Resident #65's bed was set to the proper setting to ensure comfort. This affected one resident (#65) of 18 reviewed for speciality mattresses. The facility census was 91.
- 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 resident interview, family interview, staff interview, and policy review, the facility failed to ensure care conferences were held quarterly. This affected three residents (#22, #68, and #79) of six residents reviewed for care conferences. The facility census was 91.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide and offer Resident #65 activities per preference. This affected one resident (#65) of one resident reviewed for activities. The facility census was 91.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to identify and assess new skin impairment timely. This affected one resident (#62) of four reviewed for skin. Facility census was 91.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure tube feed was labeled and dated. This affected one resident (#79) of one reviewed for tube feed. The facility census was 91.
April 29, 2024Complaint inspection · 2 citations
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, staff interview and review of manufacturer's instructions, the facility failed to ensure medication error rates were not five percent or greater when staff failed to prime two insulin pens for Resident #7. There was 32 medication administration opportunities with two errors, for a medication error rate of 6.25%. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, medical record review, staff interview, and review of insulin pen manufacturer's instructions, the facility failed to ensure residents were free from significant medication errors when staff failed to prime two insulin pens for Resident #7. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93.
September 25, 2023Complaint inspection · 2 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 medical record review, staff and resident interview, and policy review the facility failed to ensure care conferences were provided quarterly for the residents. This affected three (#6, #20, and #42) of three residents reviewed for care conferences. The facility census was 97.
- 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 medical record review, staff interview, observation, and policy review, the facility failed to ensure a resident, who was incontinent of bowel and bladder and dependent on staff for toileting, received the appropriate treatment and services for incontinence care. This affected one (#42) of three residents reviewed for incontinence care. The facility identified there were 22 residents who were incontinent of bowel and/or bladder. The facility census was 97.
February 11, 2022Standard inspection · 12 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, observations, interviews with staff, a family member and Nurse Practitioner (NP) #263, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement pressuring relieving interventions for a resident at risk for further skin breakdown due to existing pressure ulcers and failed to complete weekly skin assessments. This resulted in Actual Harm when staff failed to implement pressure relieving interventions to prevent further skin breakdown for Resident #49 resulting in the development of an avoidable Deep Tissue Injury (DTI) to the left heel. Resident #49 also had increased measurements in the coccyx and heel pressure ulcers and experienced discomfort during a dressing change. This affected one (#49) of four residents reviewed for pressure ulcers. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, staff interviews, review of Center for Disease Control and Prevention (CDC) guidleines, facility policy review, the facility failed to maintain infection control practices to prevent the spread of COVID-19. This had the potential to affect all residents except the eight COVID-19 positive residents (#5, #17, #20, #23, #44, #85, #90 and #394). Additionally, the facility failed to maintain acceptable infection control practices when handling medications. This deficient practice affected one (#43) of five residents reviewed for medication administration. The facility census was 91.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review, resident and staff interviews, and review of policy, the facility failed to conduct quarterly care conferences for one resident. The affected one (#65) of three residents reviewed for care conferences. The facility census was 91.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, medical record review, resident and staff interviews, the facility failed to ensure a resident was provided with a bed mobility devices to assist with bed mobility. This affected one (#85) of one resident reviewed for bed mobility. The facility census was 91.
- 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 and staff interviews, the facility failed to complete documentation and obtain written consent from the resident or resident representative for a change in code status. This affected one (#64) of one resident reviewed for advanced directives. The facility census was 91.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interview, the facility failed to complete a Prea-dmission Screening and Resident Review (PASARR) when for a residnet with a new mental diagnosis and failed to complete accurate PASARR's asseements. This affected three (#32, #58, #69) of three residents reviewed for PASARR's. The facility census was 91.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, record review, family and staff interviews, the facility failed to provide individualized activities to meet the needs and interest for one resident. This affected one (#49) of three reviewed for activities. Facility census was 91.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, staff and family interviews, the facility failed to encourage fluids per physician orders, monitor oral intake of fluids, and obtain weights according to physician orders. This affected one (#49) of eight residents reviewed for nutrition and hydration. Facility census was 91.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record and staff interview, the facility failed to implement pharmacy recommendations. This affected one (#69) of five residents reviewed for unnecessary medications. The facility census was 91.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff interview, review of policy, the facility failed to hold blood pressure medication when a resident's blood pressure was outside of the parameters (Resident #88). The facility also failed to monitor edema while on a diuretic medication and monitor bruising while on an anticoagulant medication for a resident (Resident #37). The deficient practices affected two (Residents #37 and #88) of six residents reviewed for unnecessary medications. The facility census was 91.
- 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 interview, and policy review, the facility failed to ensure medication were not left on resident's bedside and failed to ensure resident did not have medications that was not prescribed to her by the physician in her room. This affected two (#4 and #6) of five residents review medication. The facility census was 91.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and staff interview, the facility failed to keep an accurate medical record, when the nurse signed off on a skin assessment prior to completing it. This affected one (#37) of five residents reviewed for unnecessary medications. The facility census was 91.
Fire safety inspections
8 fire safety citations on file: 1 on February 10, 2026, 4 on July 25, 2024, 3 on February 11, 2022.
Every fire safety citation8 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 · February 10, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 25, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 25, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 25, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 25, 2024 · Corrected (the home has a date of correction)
- F
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · February 11, 2022 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · February 11, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 11, 2022 · Corrected (the home has a date of correction)