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
0G
0H
0I
Potential for more than minimal harm
16D
1E
0F
Potential for minimal harm
0A
0B
0C
August 26, 2025Standard inspection · 4 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders related to monitoring vital signs prior to medication administration for 1 of 13 residents reviewed for Quality of Care. (Resident 16)
- 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 observation, interview, and record review, the facility failed to follow appropriate infection control guidelines during indwelling urinary catheter care for 1 of 2 residents reviewed for Catheters/Urinary Tract Infections (UTI). (Resident 6)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines during medication administration for 1 of 11 medication administration observations.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate and accurate antibiotic stewardship was implemented related to tracking and trending of infections for 1 of 6 residents reviewed for antibiotic stewardship. (Resident 8)
October 2, 2024Standard 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 record review and interview, the facility failed to notify a physician related to obtaining a urinalysis for 1 of 13 residents reviewed for notification of change. (Resident 21)
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on record review and interview, the facility failed to obtain diagnostic services in a timely manner for 1 of 13 residents reviewed for radiology and diagnostic services. (Resident 6)
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to acknowledge a resident had dentures and notify the dentist of lost dentures in a timely manner for 1 of 1 resident reviewed for dental. (Resident 36)
October 11, 2023Complaint inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to residents' diagnoses of urinary tract infections for 2 of 3 residents reviewed for accuracy of assessments. (Residents F and B)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines during toileting care for 1 of 5 residents reviewed for infection control. (Resident E)
August 2, 2023Standard inspection · 8 citations
- E
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 and interview, the facility failed to store medications appropriately related to having multiple unsecured loose tablets in the medication carts for 3 of 3 medication carts reviewed. (Medication Carts on the 200 Hall, 300 Hall, and 100 Hall)
- 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 observation, interview, and record review, the facility failed to appropriately notify the physician in a timely manor for a resident's change in condition related to a fall for 1 of 14 residents reviewed for notification of change. (Resident 24)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to special treatments, falls, and nutritional status for 3 of 14 residents reviewed for accuracy of assessments. (Residents 9, 30, and 37).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to complete neurological assessments after a fall for 1 of 6 residents reviewed for accidents. (Resident 30)
- 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 and record review, the facility failed to ensure a resident that was incontinent of bowel received appropriate treatment and services to maintain a healthy bowel elimination pattern for 1 of 2 residents reviewed for bowel and/or bladder function. (Resident 35)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physicians orders related to medication hold parameters for 2 of 6 residents reviewed for unnecessary medications. (Residents 4 and 38)
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain laboratory results and communicate with the physician in a timely manner for 1 of 16 residents reviewed for laboratory services. (Resident 4)
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to maintain a facility pantry snack refrigerator for all residents related to unlabeled items and outdated items for 1 of 1 snack refrigerator reviewed.
Fire safety inspections
13 fire safety citations on file: 2 on August 26, 2025, 1 on October 2, 2024, 10 on August 2, 2023.
Every fire safety citation13 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 26, 2025 · 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 · August 26, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 2, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · August 2, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 2, 2023 · Waiver
- E
Install corridor and hallway doors that block smoke.
K 363 · August 2, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 2, 2023 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · August 2, 2023 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 2, 2023 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · August 2, 2023 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · August 2, 2023 · Corrected (the home has a date of correction)
- C
Develop a communication plan.
E 29 · August 2, 2023 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · August 2, 2023 · Corrected (the home has a date of correction)