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 17 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
0E
0F
Potential for minimal harm
0A
1B
0C
June 26, 2025Standard inspection, Complaint inspection · 4 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was safely transferred by a Hoyer (mechanical lift) for 1 of 2 residents randomly observed for transfers. (Resident 253)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely develop a person-centered behavior management care plan with individualized interventions and document approaches to care for a resident with dementia with behaviors of wandering for 1 of 2 residents reviewed for accidents. (Resident 1)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed after doffing gloves for 1 of 1 resident reviewed for urinary catheter and 1 of 2 residents observed for blood sugar testing. (Resident B and Resident C)
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and reduce antibiotic resistance related to prescribing antibiotics without adequate indications for use based on the McGeer criteria and were able to treat the bacteria causing the infection for 1 of 1 resident reviewed for urinary catheters (Resident B).
June 14, 2024Standard inspection · 3 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff accurately identified and monitored skin impairment for a cognitively impaired, dependent resident at risk to develop pressure injuries, failed to ensure interventions for effective pressure relief, and to promote healing, were implemented when an area of concern on the resident's skin was reported to a nurse, and failed to ensure care and services were provided to prevent the pressure injury from deteriorating for 1 of 2 residents reviewed for skin integrity (Resident 50). This deficient practice resulted in Resident 50 developing a facility-acquired stage three (full thickness tissue loss) pressure injury.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely complete a Significant Change of Status MDS (Minimum Data Set) Assessment for a resident receiving hospice services and to ensure a Minimum Data Set (MDS) Assessment was accurately completed for dental issues for 1 of 1 resident reviewed for Resident Assessment (Resident 45) and 1 of 1 resident reviewed for dental (Resident 16).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to use gloves and perform hand hygiene when providing care to a resident whose leg was bleeding in the common area of the unit for 1 of 1 resident randomly observed. (Resident 40)
May 19, 2023Standard inspection · 10 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to take prompt efforts to resolve an oral grievance from a resident regarding missing clothing items for 1 of 1 residents reviewed for personal property. (Resident 6)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a humidifier was provided for a resident using oxygen therapy for 1 of 1 resident reviewed for oxygen. (Resident 21)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to address a resident's pain utilizing nonpharmacological interventions for 1 of 1 residents reviewed for pain. (Resident 21)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate dementia care services to 1 of 6 residents reviewed for dementia care. (Resident 24)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free of unnecessary mediations with antibiotic usage for 1 of 1 residents reviewed for antibiotic medications. (Resident 1)
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 1 of 4 residents observed during medication pass. There were 25 opportunities with 2 errors resulting in an 8% medications error rate. The errors involved 1 resident (Resident 3) in the sample of 4.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review, the facility failed to provide a speech evaluation, as ordered by the physician, for a resident requesting a diet upgrade for 1 of 1 resident reviewed for nutrition (Resident 48).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by not ensuring: a urinary catheter bag was off of the floor for 1 of 1 residents reviewed for urinary catheter (Resident 14 ); medication cups, water cups, and plastic sleeves which are used to crush medications in were not handled in a manner to prevent staff from placing fingers and/or fingernails inside the cup or a disposable plastic pouch for 2 of 4 residents observed during medication administration (Residents 36, 56, and 3 ); and not performing proper hand hygiene prior to donning and doffing of gloves for 1 of 4 residents reviewed for medication administration (Resident 33)
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, the facility failed to track and monitor antibiotic usage to ensure resident's did not receive prophylactic antibiotics for 1 of 1 residents reviewed for antibiotic medications. (Resident 1)
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to timely complete and transmit discharge tracking forms for 5 of 17 resident reviewed for Minimum Data Set Assessments (Resident 12, 23, 53, 59, and 60).
Fire safety inspections
18 fire safety citations on file: 6 on June 26, 2025, 8 on June 14, 2024, 4 on May 19, 2023.
Every fire safety citation18 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 26, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 26, 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 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · June 26, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 14, 2024 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · June 14, 2024 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · June 14, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 14, 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 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 14, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 19, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 19, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 19, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements that are deficient.
K 300 · May 19, 2023 · Corrected (the home has a date of correction)