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
13D
1E
1F
Potential for minimal harm
0A
0B
0C
April 28, 2025Standard inspection, Complaint inspection · 10 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 observation, interview and policy review, the facility failed to have test strips at the three-sink manual dishwash area to test for proper sanitation levels. This had the potential to affect all 59 of 59 residents receiving dietary services.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure insulin pens were only used for one resident and failed to follow infection control precautions for Resident #32 and #73. This affected Resident #5, Resident #32, and Resident #73 with the potential to affect five residents (#42, #70, #71, #72, and #73) who resided on the 100 hall. The facility census was 59.
- 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 medical record review, interview, and review of facility policy, the facility failed to ensure Resident #2 and Resident #18's comprehensive care plans included all goals and interventions needed to meet the residents' total care needs. This affected two residents (Resident #2 and Resident #18) of 27 residents reviewed for comprehensive care plans.
- 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 review of the medical record, interview, and review of facility policy, the facility failed to ensure the care plan for Resident #4 was updated with new fall interventions after a fall with injury. This affected one resident (Resident #4) of two residents reviewed for accidents. The facility census was 59.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of the medical record, interview, and review of facility policy, the facility failed to ensure Resident #2 received assistance with baths and showers per preferences or the care plan. This affected one resident (Resident #2) of six residents reviewed for activities of daily living (ADL). The facility census was 59.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility failed to ensure Resident #66's nicotine patch was administered as ordered. This affected one residents (Resident #66) of five residents reviewed for quality of care.
- 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, interview, and review of facility policy, the facility failed to ensure Resident #65's care needs were addressed related to a urine sample and the results of the urine analysis were properly followed up on. This affected one resident (Resident #65) of two residents reviewed for bowel and bladder continence.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to timely and accurately address and monitor significant weight loss. This affected one resident (#40) of four residents (#40, #47, #48, and #55) reviewed for nutrition. The facility census was 59.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the medical record, interview, and review of facility policy, the facility failed to ensure Resident #18 pain medications had proper indications for use, their pain was re-evaluated after administration of analgesics, and had interventions in place to ensure effective monitoring for adverse effects of opioid use. This affected one Resident (Resident #18) of five residents reviewed for unnecessary medications. The facility census was 59.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility failed to administer medications with an error rate of under 5%. Two medication errors out of 29 opportunities for error, creating a total medication error rate of 6.9%. This affected two (Resident #5 and #11) of five residents observed for medication administration.
July 23, 2024Complaint inspection · 1 citation
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately provide the physician ordered thickened liquid diet to Resident #2. This affected one resident (Resident #2) of three residents reviewed for food/nutrition. The facility identified three residents (#2, #4, and #58) who were prescribed thickened liquids. The facility census was 61.
June 13, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, interview, observation, and review of the facility policy, the facility failed to ensure proper Personal Protective Equipment (PPE) was used for Enhanced Barrier Precautions (EBP). This affected one resident (Resident #49) out of three residents reviewed for infection control. The facility census was 58.
October 13, 2022Standard inspection · 0 citations
October 31, 2019Standard inspection · 3 citations
- 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 record review and interview, the facility failed to ensure Resident #2's advance directives and physician orders accurately reflected the resident's code status. This affected one (Resident #2) of one resident reviewed for hospice.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive assessment for Resident #3 was accurate for dental and Resident #20 for life expectancy. This effected two of 20 residents whose comprehensive assessments were reviewed. The facility census was 46.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pureed foods were prepared according to the facility recipe and best practice guidelines. This affected four (Residents #2, #8, #19 and #22) of four residents the facility identified as requiring pureed meals. Facility census was 46.
Fire safety inspections
7 fire safety citations on file: 4 on April 28, 2025, 1 on October 13, 2022, 2 on October 31, 2019.
Every fire safety citation7 citations
- F
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 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · April 28, 2025 · Corrected (the home has a date of correction)
- F
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)
- 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 · October 31, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 31, 2019 · Corrected (the home has a date of correction)