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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
2F
Potential for minimal harm
0A
0B
0C
June 13, 2025Standard inspection · 2 citations
- F
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, interview and record review the facility failed to dispose of vials of multi dose medications after open date had expired for greater than 30 days. This has the potential to affect all 39 residents living in the facility.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation and interview, the facility failed to provide dietary supplements to prevent weight loss and follow fluid restriction orders to prevent fluid overload for 2 (R9, R144) of 4 residents reviewed for nutrition in the sample of 22.
August 2, 2024Standard inspection · 0 citations
August 17, 2023Standard inspection · 4 citations
- F
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Inspectors wroteBased on observation, interview and record review the facility failed to allow freedom of visitation at any time. This has the potential to affect all 22 residents residing at the facility.
- 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 interview and record review, the facility failed to notify the physician of changes in a resident's weight for one resident of 4 residents (R31) reviewed for physician notification in a sample of 22. Findings Include: R31's Face Sheet documents R31 is an [AGE] year-old female resident with an admittance date of 10/10/17. R31's Face Sheet documents diagnosis including: Cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic neuropathy, Edema, Arthropathy, Essential hypertension, Dysphagia, Acute upper respiratory infection, Iron Deficiency anemia, and Barrett's esophagus without dysplasia. R31's Physician Order Sheet documents an order for Metformin tablet 1000 mg (milligrams) twice a day with a start date of 04/04/2021 and a discontinued date of 04/26/23. [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure restorative programs were implemented for 1 of 8 (R25) residents reviewed for restorative care in the sample of 22. Findings Include: R25's Face Sheet with a print date of 8/17/23 documents R25 was admitted to the facility on [DATE] with diagnoses that include Stage 3 pressure ulcer left hip, spondylosis, osteoarthrosis of spine, dementia, mood disturbance, and cognitive communication deficit. R25's Minimum Data Set (MDS) dated [DATE] documents R25 has a severe cognitive impairment. This same MDS documents under Section G, R25 is totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. R25's Care Plan dated 6/28/23 documents a problem area with a start date of 4/8/23, Category: [...]
- 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 interview, record review, and observation the facility failed to ensure staff provided urinary catheter care and performed hand hygiene per current standards of practice for 2 of 3 (R23 and R28) residents reviewed for catheter care in the sample of 22. Findings Include: 1. R23's Face Sheet with a print date of 08/17/23 documents R23 was admitted to the facility on [DATE] with diagnoses that include orchiectomy, congestive heart failure, acute kidney failure, benign prostatic hyperplasia (BPH), urinary retention, obstructive and reflux uropathy, and history of urinary tract infection. R23's MDS (Minimum Data Set) dated 6/9/23 documents a BIMS (Brief Interview for Mental Status) score of 09, which indicates R23 has a moderate cognitive deficit. R23's current Care Plan dated 4/18/23 documents a problem area with a start date of 12/10/2019 of, Category: [...]
Fire safety inspections
21 fire safety citations on file: 8 on June 13, 2025, 9 on August 2, 2024, 4 on August 17, 2023.
Every fire safety citation21 citations
- F
Address subsistence needs for staff and patients.
E 15 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 13, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 13, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 13, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 2, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 2, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 2, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 2, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 17, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · August 17, 2023 · Corrected (the home has a date of correction)