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
September 10, 2025Standard inspection · 2 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 wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Cart B) and 1 of 1 medication storage rooms, reviewed for medication storage.- The facility failed to ensure 2 albuterol inhalers without an open date for Resident #24 and a Fluticasone-Salmeterol inhaler without an open date for Resident #24, were removed from Medication Cart B.- The facility failed to ensure a box of Juven packets with 19 packets in it, expired 9/1/25, and a glucose test trip bottle without an open date on it, were removed from Medication Cart B.- The facility failed to ensure a box of Align with 7 capsules in it, expired 8/31/25, was removed from the medication storage room. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 28 opportunities, which involved 1 of 4 residents (Resident #13) reviewed for medication administration.- RN A failed to administer Fluticasone Propionate nasal spray 50mcg/act, Biotin 5000mcg, and Magnesium Oxide 400mg to Resident #13 on 9/9/25, resulting in missed doses. This failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.
August 21, 2024Standard inspection, Complaint inspection · 5 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of (Resident #20, Resident #8 and Resident #2) of 8 residents whose records were reviewed for accurate assessments. -The facility failed to list Resident #20's fall on 1/8/24 and 6/14/24 on the MDS. -The facility failed to list Resident #8's oxygen continuously at 2 lpm via NC, on the MDS. -The facility failed to list Resident #2's oxygen PRN at 2 lpm via NC, on the MDS. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being.
- 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 that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 8 residents (Resident #15) reviewed for oxygen therapy. - Resident #15's oxygen setting was on 4 L instead of 2 L as ordered by the physician. This failure could place residents at risk of adverse side effects or inadequate therapeutic outcomes.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the resident for risk of entrapment, reviewed the benefits of bed rails with resident and resident representative, obtained Physician consent prior to use for 2 of 8 residents (Resident #11 and Resident #3) reviewed for bed rails. -The facility failed to obtain a physician's order, assess the need for, and consent for Resident #11's bed rails. -The facility failed to obtain a physician's order and consent for Resident #3's bed rails. This failure could place residents with bed rails at risk of restricted movement, entrapment, decline in ADLs function, and psychological distress.
- 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, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in accordance with professional standards for food safety in 1 of 1 facility kitchen . -The facility failed to ensure [NAME] A wore a hair restraint while preparing meals in the kitchen. This failure could place residents receiving food from the facility kitchen at risk for cross contamination.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #138) of 8 residents reviewed for infection control. -CNA B failed to wear appropriate PPE and change her gloves when she provided incontinence care to Resident #138, who was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building.
June 30, 2023Standard inspection · 1 citation
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on interview, observation, and record review the facility failed to prepare food in accordance with professional standards for food service safety in 1 of 3 kitchens in that: The facility failed to ensure that all dietary personnel in the food preparation area wore a hair restraint or head covering. This failure could place residents that consume facility prepared meals at risk for physical contamination of food by hair.
Fire safety inspections
8 fire safety citations on file: 1 on September 10, 2025, 6 on August 21, 2024, 1 on June 30, 2023.
Every fire safety citation8 citations
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 10, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · August 21, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 21, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 21, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 21, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 21, 2024 · Corrected (the home has a date of correction)
- C
Have properly installed electrical wiring and gas equipment.
K 511 · August 21, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 30, 2023 · Corrected (the home has a date of correction)