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
0G
0H
0I
Potential for more than minimal harm
25D
0E
0F
Potential for minimal harm
0A
0B
0C
April 24, 2025Standard inspection · 10 citations
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on policy review, financial document review, medical record review, and interview, the facility failed in their fiduciary responsibility in holding, safeguarding, managing, and accounting for the deposited personal funds for 13 of 80 (Resident #3, #5, #15, #48, #51, #58, #75, #80, #84, #92, #97, #116, and #119) sampled residents.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on facility policy review, personnel file review, medical record review, facility documentation review, and interview, the facility failed to ensure the residents' rights to be free from misappropriation of property due to diversion of medications including controlled substances was maintained for 3 residents (Resident #911, #910, and #52) of 13 residents reviewed for misappropriation of resident property.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on policy review, medical record review, observations, and interviews the facility failed to provide adequate personal hygiene and bathing for 2 of 4 residents (Resident #81 and Resident #131) reviewed for Activities of Daily Living (ADL's).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to follow a physician's order related to narcotic medication administration for 4 residents (Resident #917, #66, #908, and #909) of 13 residents reviewed for narcotic medication administration.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical records review, observations, and interview, the facility failed to follow physician orders for 1 of 3 (Resident #493) sampled residents.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to properly destroy narcotic medications for 1 resident (Resident #918) of 13 residents reviewed for narcotic medication use.
- 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 the policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when there was opened and undated medication on 1 of 19 (medication cart 1B) med storage areas.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide dental services for 1 of 2 (Resident #130) reviewed for dental services.
- 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 interview, the facility failed to maintain accurate medical records related to dental appointments for 1 of 2 (Resident #130) reviewed for dental services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on the policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 6 staff members (Licensed Practical Nurse (LPN) DD) failed to disinfect reusable equipment before use and after use and failed to properly perform hand hygiene. When 2 of 2 staff members (Certified Nurse Assistant (CNA) EE and Registered Nurse (RN) FF) failed to wear Personal Protective equipment (PPE) in a Contact Isolation room and during direct care in an Enhanced Barrier Precautions room.
April 28, 2023Standard inspection · 7 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on facility policy review, observations, and interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment in 9 of 106 rooms (#301, #322, #324, #325, #326, #327, #328, #329, and #330) observed.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to conduct a thorough investigation in response to allegations of misappropriation for 1 of 21 (Resident #118) sampled residents reviewed for abuse.
- 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 and interview, the facility failed to conduct care plan conferences for 4 of 56 (Resident #39, #69, #81 and #103) sampled residents reviewed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observations, and interviews, the facility failed to ensure a wound dressing was maintained according to professional standards of practice for 1 of 9 sampled residents (Resident #185) reviewed.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a Peripheral IV (intravenous) catheter was administered and maintained according to professional standards of practice for 1 of 3 sampled residents (Resident #185) reviewed.
- 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 medical record review and interview, the facility failed to evaluate and have behavior monitoring for 1 of 5 (Resident #136) sampled residents for unnecessary medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews the facility failed to properly store oral hygiene equipment in a sanitary manner for 5 of 106 resident rooms (room [ROOM NUMBER], #326, #327, #328, and #329) observed.
March 26, 2019Standard inspection · 8 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to follow physician's orders related to wound care dressing change for 1 resident (#133) of 15 residents receiving wound care.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on the medical record review, observation and interview, the facility failed to provide necessary respiratory care for residents 2 (#24 and #482 ) of 37 residents receiving respiratory services.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on the medical record review, observation, and interview, the facility failed to ensure nursing staff have the knowledge and competencies, and skill sets for staging pressure ulcer 1 resident (#100) of 15 residents with staging pressure ulcers.
- 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 facility policy review, medical record review and interview the pharmacist failed to make recommendations for a stop date related to a prn (as needed) anti-psychotic medication for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on facility policy review, medical record review and interview the facility failed to have psychotropic/antipsychotic drug side effect or behavior monitoring in place for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications.
- 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 facility policy review, medical record review and interview the facility failed to provide an adequate diagnosis and a 14 day stop date for a prn (as needed) anti-psychotic drug for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications.
- 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 facility policy review, observation, and interview, the facility failed to refrigerate and properly store medications on 4 of 12 medication carts.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation and interview the facility failed to maintain ice storage container and scoop in a sanitary manner.
Fire safety inspections
13 fire safety citations on file: 3 on April 24, 2025, 10 on April 28, 2023.
Every fire safety citation13 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2025 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Provide properly sized and located linen or trash receptacles.
K 754 · April 28, 2023 · 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 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 28, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 28, 2023 · Corrected (the home has a date of correction)