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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
15D
3E
3F
Potential for minimal harm
0A
0B
0C
August 22, 2025Complaint inspection · 1 citation
- 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, record review, policy review and staff interview, the facility failed to ensure medications were administered under staff supervision and not left unsupervised at the resident's bedside. This affected one (Resident #102) of three residents reviewed for medications.
May 15, 2025Standard inspection · 4 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, policy review, observation, interview, and Resident Council Minute review revealed the facility failed to ensure requests for assistance with activities of daily living were provided timely for two dependent residents. This affected two (Resident #23 and Resident #55) of three residents reviewed for activities of daily living (ADL's). The facility census was 101.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, interview and medication guideline review, the facility failed to ensure a medication error rate of less than five (5) percent (%). Observation of 36 medications administered with three errors revealed a medication error rate of 8.33%. This finding affected two residents (Residents #18 and #74) of four residents observed for medication administration.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure residents were served the correct diet and diet texture as ordered. This affected one resident (Resident#7) of five residents reviewed for therapeutic diets. The facility census was 101.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, staff interview and facility policy review, the facility failed to maintain infection control procedures during meal service. This affected one resident (Resident #21) of eight residents who required assistance with eating. The facility census was 101. Findings Include: A review of Resident #21's medical record revealed an admission date 03/13/24 with diagnoses including history of stroke, dysphagia, type two diabetes, and chronic obstructive pulmonary disease (COPD). A review of Resident #21's physician's orders revealed an order dated 08/15/24 for LCS (Low Concentrated Sweets) diet Regular texture, Regular/Thin consistency, all liquids with small-bore straw. Cut food into bite-sized pieces. [...]
April 11, 2024Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, hospital record review, policy review and interview the facility failed to adequate monitor and seek timely medical intervention/hospitalization following a significant change in condition for Resident #31. This affected one resident (#31) of three reviewed for change in condition. Actual Harm occurred on 03/29/24 when Resident #31, who was severely cognitively impaired was transferred to the emergency room where he was intubated and admitted to the intensive care unit for respiratory failure and sepsis. On 03/11/24, Resident #31 was observed unresponsive and having seizure-like activity. He was a full code with no history of seizures. [...]
January 25, 2024Standard inspection · 8 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 interview, observation, and review of facility policy, the facility failed to ensure that food was stored under sanitary conditions. This had the potential to affect all residents in the facility. The facility was 107.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of restorative nursing documentation, staff interview, resident interview, and review of facility policy, the facility failed to ensure restorative nursing services were documented accurately. This affected three residents (#30, #71, and #82) of three residents reviewed and had the potential to affect all 59 residents identified by the facility as receiving restorative nursing services for range of motion and ambulation. The facility census was 107.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure physician notification was completed related to weight changes. This affected one (Resident #38) of one resident reviewed for weight gain. The facility census was 107.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-Assessment Screenings (PAS) were accurately completed upon admission for Resident #71 and Resident #81. This affected two (Resident #71 and #81) of three residents reviewed for PAS. The facility census was 107.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, observation and interview, the facility failed to ensure glasses were obtained in a timely manner for Resident #81. This affected one (Resident #81) of one residents reviewed for vision services. The facility census was 107.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, medical record review, policy review and staff interview the facility failed to ensure residents received medications as ordered by the physician. This resulted in a medication error rate of 8% with two medication errors out of 25 medications administered. This affected one (Resident #34) of three residents observed for medication administration. The facility census was 107.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on record review and interview, the facility failed to arrange dental consults as ordered and complete oral assessments as part of the resident's comprehensive dental care. This affected one (Resident #81) of one resident reviewed for dental services. The facility census was 107.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure ordered antibiotics were reviewed and/or only administered with adequate indications for use. This affected three (Residents #69, #72 and #101) of seven residents reviewed for antibiotic use. The facility census was 107.
March 3, 2022Standard inspection · 8 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, review of an invoice, and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent contamination of food. This had the potential to affect all 85 residents.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record reviews, observation, interviews, and policy review, the facility failed to ensure goggles were sanitized upon exiting Resident #37's room, who was under droplet isolation precautions, and failed to ensure proper signage was displayed prior to entering Resident #21 and Resident #133 rooms who were reported to be on isolation precautions. This affected three residents (Resident #21, Resident #37, and Resident #133) with the potential to affect all 85 residents in the facility.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview, record review, and policy review , the facility failed to offer residents a preference in bathing frequency. This affected four residents (Resident #28, #75, #77, and anonymous) of four residents reviewed for choices.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were provided the option to attend the Resident Council meetings, nor were resident concerns documented and no evidence was provided indicating concerns were addressed timely. This had the potential to affect 79 of 85 residents residing in the facility, as Resident #11, #20, #22, #28, #29, and #78 regularly attended resident council.
- 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 staff interview, the facility failed to ensure advance directives were accurately documented on all sources. This affected three residents (Resident #27, #40, and #66) of 24 residents reviewed for advanced directives.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on review of Skilled Nursing Facility (SNF) beneficiary non-coverage notifications and interview, the facility failed to consistently provide written notification of services that would no longer be covered by Medicare Part A. This affected two residents (Residents #58 and #68) of three residents reviewed for notification of termination of Medicare Part A services.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, review of wound practitioner notes, interviews, and policy review, the facility failed to ensure pressure relieving interventions were in place per the plan of care, treatments were administered per orders, and assessments and staging of pressure ulcers were accurate. This affected one resident (Resident #27) of one resident reviewed for pressure ulcers
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #11 received foods and liquids at the appropriate texture per dietary orders. This affected one resident (Resident #11) of five residents reviewed.
Fire safety inspections
5 fire safety citations on file: 2 on May 15, 2025, 1 on January 25, 2024, 2 on March 3, 2022.
Every fire safety citation5 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 15, 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 · January 25, 2024 · Corrected (the home has a date of correction)
- 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 · March 3, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 3, 2022 · Corrected (the home has a date of correction)