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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
2E
0F
Potential for minimal harm
0A
0B
0C
June 18, 2025Complaint inspection · 2 citations
- J
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 staff interview, clinical record review and facility document review the facility staff failed to accurately label medications for 1 of 2 residents, Resident #1.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, clinical record review, and facility policy review the facility staff failed to follow professional standards of practice for the administration of medications for 1 of 2 residents, Resident #1.
April 25, 2024Standard inspection, Complaint inspection · 12 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 4 of 26 residents, #57, #76, #18, and #44.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 26 residents was clinically appropriate for self-administration of medications.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 26 residents, Resident #50.
- 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 observation, staff interview, resident interview, clinical record review, and facility document review the facility staff failed to develop a comprehensive care plan for 2 of 26. residents, #50 and #56.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview, clinical record review, and facility document review the facility staff failed to ensure 1 of 26 residents was free from unnecessary medications, Resident #44.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to provide adequate monitoring for residents receiving psychotropic medications for one of 26 residents in the survey sample, resident # 65.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview,clinical record review, and facility document review the facility staff failed to ensure 1 of 26 residents was free of significant medication errors, Resident #6.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wrote3. For Resident #60, the facility staff failed to document in the clinical record the responsible party's decision to decline the influenza, pneumococcal, and updated 2023-2024 formula COVID-19 vaccines. Resident #60's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Panic Disorder, and Psychotic Disorder with Delusions. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/17/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. According to Resident #60's immunization history documented in the clinical record, the resident had previously received COVID-19 vaccines on 1/25/21, 2/15/21, 6/14/22, 10/20/22 and the most recent influenza vaccine was received on 10/12/22. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to ensure individuals providing resident care correctly performed hand hygiene.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine to 2 of 5 sampled residents (Resident #24 and #76) in accordance with nationally recognized standards. 1. For Resident #24, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, and Thoracic Aortic Aneurysm. [...]
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer an updated 2023-2024 formula COVID-19 vaccine for 3 of 5 sampled residents, Resident #3, #24, and #75.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interviews and clinical record review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming, personal and oral care for one (1) of 26 sampled residents, Resident #62.
October 13, 2022Standard 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, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications/supplements were stored in a locked compartment in a resident room for 1 of 24 (Resident #27), failed to label and store medication appropriately on 1 of 4 wings (wing 1), failed to keep medications in direct line of sight until administered for 1 of 4 Residents during a medication pass (Resident #10), and failed to lock an unattended medication cart on 1 of 4 wings (wing 3).
- 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 staff interview, clinical record review, and facility document review, the facility staff failed to ensure drug regimen reviews were acted upon for 2 of 5 residents in the survey sample reviewed for unnecessary medications, Resident #75 and #37.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interview, facility document review, and during a medication pass and pour observation, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary, environment and help prevent the development and transmission of communicable disease and infections on 1 of 4 facility wings, Wing #3.
December 5, 2019Standard inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for one of 28 residents, Resident #41.
- 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 facility document review, the facility staff failed to store expired biological's in 2 of 4 medication rooms (unit 1 and unit 2) and failed to properly store an unused IV antibiotic for 1 of 28 Residents, Resident #94.
Fire safety inspections
17 fire safety citations on file: 2 on April 25, 2024, 10 on October 13, 2022, 5 on December 5, 2019.
Every fire safety citation17 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 25, 2024 · Corrected (the home has a date of correction)
- B
Install an approved automatic sprinkler system.
K 351 · April 25, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 13, 2022 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 13, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · October 13, 2022 · Waiver
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 13, 2022 · Waiver
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · October 13, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 13, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 13, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 13, 2022 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · October 13, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 13, 2022 · 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 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 5, 2019 · Corrected (the home has a date of correction)
- D
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 · December 5, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 5, 2019 · Corrected (the home has a date of correction)