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 11 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
1F
Potential for minimal harm
0A
0B
0C
August 21, 2025Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policies titled, Food Receiving and Storage, Refrigerators and Freezers, and Food Brought by Family/Visitors, the facility failed to remove expired food items from the refrigerator and dry storage, failed to label and date an opened package of frozen food, failed to maintain cleanliness of the kitchen's ice machine, failed to remove expired items from a resident's personal refrigerator, failed to maintain cleanliness of a resident's personal refrigerator, and failed to serve cold and hot food at an appropriate temperature. The deficient practices had the potential to cause foodborne illness and to affect 107 residents who received food from the kitchen. The facility census was 109.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Resident Self-Administration of Medication, the facility failed to adequately assess two of 59 sampled Residents (R) (R60, R75) for self-administration of medication. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide oxygen (O2) tubing extensions for one of 15 residents (R) (R68) who received O2 therapy. The deficient practice had the potential to cause issues with mobility and independence. Findings Include:Review of the electronic medical record for R68 revealed admission to the facility with diagnoses of coronavirus disease (Covid-19), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and shortness of breath (SOB). Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented that R68 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure safe medication administration practices for one of nine residents (R) (R3) receiving insulin. Specifically, the facility failed to ensure R3 did not receive Humalog insulin from a vial that was not intended for R3.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure the incentive spirometer (device to improve lung function) was properly stored in a manner to prevent contamination for one of 14 residents (R) (R60) using respiratory equipment. The deficient practice had the potential to increase the risk of respiratory infection for R60.
March 14, 2024Standard inspection · 4 citations
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) after a significant change occurred for one of 50 sampled residents (R) (R44). The facility census was 107 residents.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Care Plans - Baseline, the facility failed to add anticoagulant (blood clotting medication) use to the baseline care plan for one of 50 sampled residents (R) (R267). The deficient practice had the potential for lack of interventions to monitor anticoagulant treatment that could lead to blood clotting issues.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to maintain respiratory equipment consistent with professional standards for three of 50 sampled residents (R) (R91, R74, and R271). Specifically, the facility failed to bag a CPAP (continuous positive airway pressure) mask when not in use, clean/change/install filters on oxygen (O2) concentrators (machine that administers O2). The deficient practice had the potential to cause infection.
- 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 observations, resident and staff interviews and review of the facility's policy titled Medication Storage, the facility failed to discard expired biologicals prior to the expiration date printed on the medication in one of two medication storage rooms and one of seven medication carts.
January 26, 2023Standard inspection · 2 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 staff interviews, the facility failed to follow the comprehensive, person-centered care plan for one resident (R) (R#58) related to activities. Sample size was 34.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to provide an individualized, person-centered activities program to meet the needs for one resident (R)(R#58) of 34 sampled residents who needed extensive assistance by staff for provision of all care. Specifically, R#58 was not provided with person-centered activities that would meet their individual needs.
Fire safety inspections
6 fire safety citations on file: 2 on March 14, 2024, 4 on January 26, 2023.
Every fire safety citation6 citations
- D
Install corridor and hallway doors that block smoke.
K 363 · March 14, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 14, 2024 · Corrected (the home has a date of correction)
- D
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 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 26, 2023 · Corrected (the home has a date of correction)