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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
0B
0C
October 2, 2025Standard inspection · 0 citations
January 16, 2025Complaint inspection · 1 citation
- 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 resident's family interview, staff interviews and record review the facility failed to ensure 1 (Resident #2) of 3 grievances reviewed had documentation of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the complainant's concern(s), a statement as to whether the complaint was confirmed or not confirmed, and the complainant was given a summary of the pertinent findings or conclusions regarding their concern(s).
November 16, 2023Standard inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to accurately transcribe medication orders upon admission for 1 (Resident #118) of 6 residents reviewed for physicians orders.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to accurately transcribe physician's admitting pain medication orders on admission, resulting in ineffective pain control for 1 (Resident #118) of 6 residents sampled for accuracy of physician's orders.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5%. This was evidenced by two medication errors out of 26 opportunities, resulting in a medication error rate of 7.69%.
February 17, 2022Standard inspection · 4 citations
- E
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 observations, record review and staff and resident interviews, the facility failed to ensure urinary catheters were maintained in a safe and sanitary manner for 3 (Resident #16, #32 and #37) of 3 residents sampled with indwelling urinary catheter.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident status for 2 (Resident #21 and #45) of 2 sampled residents reviewed for vision and behavior. Inaccurate MDS assessments can result in a resident not receiving appropriate health care.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, staff, and resident interviews the facility failed to ensure 1 (Resident #21) of 2 sampled residents with impaired vision receive appropriate treatment and assistance with meals.
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient dietary staff to carry out the functions of the food and the nutrition services effectively in serving meals for 3 residents (Resident #12, Resident #20, and Resident #364) of 16 residents surveyed for dietary services.
Fire safety inspections
3 fire safety citations on file: 1 on October 2, 2025, 1 on November 16, 2023, 1 on February 17, 2022.
Every fire safety citation3 citations
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · November 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 17, 2022 · Corrected (the home has a date of correction)