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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
0E
0F
Potential for minimal harm
0A
0B
0C
March 27, 2025Standard inspection · 5 citations
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, record review and interviews, the facility failed to honor the resident representative's request to ensure, 1 of 3 sampled residents reviewed for Choices, Resident #71, received a shower on the scheduled shower days.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately document the discharge status of 1 of 3 sampled residents reviewed as closed records, Resident #100.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to follow physician orders for 2 of 6 sampled residents, as evidenced by the topical cream for Resident #5 was not applied as ordered, and the blood pressure medication was not given as needed for Resident #58; and failed to follow physician orders to obtain a urology consultation as ordered for 1 of 2 sampled residents reviewed for catheters, Resident #63.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review and interviews, the facility failed to provide adequate hydration for 1 of 1 sampled resident, as evidenced by not ensuring that Resident #16 was able to have the fluids she was allowed.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on record review and interview, the facility failed to ensure physician visits in a timely manner for 1 of 2 sampled residents reviewed for catheters, Resident #63.
November 30, 2023Standard inspection, Complaint inspection · 3 citations
- 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 observations, interviews and record reviews, the facility failed to provide notification to the residents' representative after a change in condition for 2 of 23 sampled residents, Residents #31 and #3.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interviews, record review and policy review, the facility failed to provide necessary treatment and services to prevent worsening of a pressure ulcer for 1 of 2 sampled residents sampled for pressure ulcers (Resident #254).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain accuracy of records for 3 of 23 sampled residents, Residents #3 #79, and #95.
August 4, 2022Standard inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to accurately assess and reassess the efficacy of interventions for skin rash for 1 of 1 sampled resident, reviewed (Resident #92); and failed to provide post-op surgical care for 1 of 1 sampled resident, reviewed (Resident #82).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to document the location of pain for 1 of 1 sampled resident reviewed as a closed record (Resident #96); and failed to document a change in condition for 1 of 5 sampled residents reviewed for Covid-19 (Resident #21).
Fire safety inspections
8 fire safety citations on file: 2 on March 27, 2025, 1 on November 30, 2023, 5 on August 4, 2022.
Every fire safety citation8 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 30, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 4, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 4, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 4, 2022 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 4, 2022 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 4, 2022 · Corrected (the home has a date of correction)