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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
0E
0F
Potential for minimal harm
0A
1B
0C
July 27, 2026Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #5) with an allegation of neglect, the facility failed to ensure the potential abuse was reported to the state survey agency.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy/procedure, and interviews for one sampled resident (Resident #5) with an allegation of mistreatment, the facility failed to ensure an allegation of mistreatment/neglect was thoroughly investigated.
February 3, 2025Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for respiratory care, the facility failed to ensure an order was obtained timely for use of a continuous positive airway pressure machine.
October 11, 2024Standard inspection, Complaint inspection · 9 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 review of the clinical record, facility policy, and staff interviews for 1 of 3 residents (Resident #96) reviewed for weight loss, the facility failed to notify the dietician in order to make recommendations when a significant weight loss occurred.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #3) reviewed for abuse, the facility failed to report injuries of unknown source to the state agency (SA) timely.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #96) reviewed for weight loss, and for 1 of 6 sampled residents (Resident #706) reviewed for unnecessary medications, the facility failed to revise the Resident Care Plan (RCP) when a change occured.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, review of the clinical record, and interviews for the only sampled resident (Resident # 46) reviewed for Hospice, the facility failed to follow a physician's order for the application of arm protectors, for 1 of 3 residents (Resident #96) reviewed for nutrition, the facility failed to obtain and document the resident's weekly weights per physician orders for a resident with a significant weight loss.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for positioning and mobility, the facility failed to provide range of motion (ROM) to a dependent resident.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, observations, review of facility policy and staff interviews for 2 of 3 residents, (Resident #96 and #406), reviewed for nutrition and hydration, for Resident #96 the facility failed to implement interventions for a resident who continued to experience significant weight loss, and for Resident #406, the facility failed to consistently document intake and output for a resident on intravenous hydration.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #85) reviewed for hospitalization, the facility failed to ensure that a resident who was hospitalized for digoxin toxicity did not receive the same high risk medication (digoxin) on readmission from the hospital which resulted in a significant medication error.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on review of the clinical record, facility documentation and interviews for the only sampled resident, (Resident #46), reviewed for hospice, the facility failed to collaborate and communicate the provision of hospice services with the contracted hospice provider.
- B
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on interviews, observations and facility policy for the only sampled resident (Resident #96) reviewed for cultural food preferences, the facility failed to ensure the dietician identified and provided Halal cuisine.
August 14, 2024Complaint inspection · 1 citation
- 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 clinical record review, interviews and facility documentation for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to report a change of condition to the physician and/or Advanced Practice Registered Nurse timely.
June 30, 2022Standard inspection · 4 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, clinical record review, facility documentation and facility policy review for one of five sampled residents (Resident #21) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure that Resident #21 was provided with incontinence care timely.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observations, and interviews for one of five units reviewed for respiratory equipment, the facility failed to appropriately store Resident #145's Continuous Positive Airway Pressure (C-PAP) mask while not in use.
- D
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 review of the clinical record, observations, facility policy review, and interviews for one of three units reviewed for medication storage, the facility failed to discard Resident #46's expired Insulin and failed to date a multidose medication vial after opening.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of one resident (Resident #37) reviewed for medication administration, the facility failed to ensure a therapeutic diet when administering a liquid oral supplement.
October 3, 2019Standard inspection · 2 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Resident #79 and #249) who required staff assistance with personal hygiene, the facility failed to ensure the number of designated staff in accordance with the physician orders were present while providing care.
- D
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 observations and interview, for one of two medication rooms reviewed during the medication storage and labeling review, the facility failed to ensure expired supplements were removed from the supply.
Fire safety inspections
5 fire safety citations on file: 4 on October 11, 2024, 1 on October 3, 2019.
Every fire safety citation5 citations
- D
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 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 11, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 3, 2019 · Corrected (the home has a date of correction)