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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
0E
1F
Potential for minimal harm
0A
0B
0C
April 16, 2025Standard inspection, Complaint inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Oxygen Administration via Concentrator, the facility failed to ensure that oxygen therapy was administered in accordance with the physician's orders for two of 23 residents (R) (R77 and R29) with physician's orders for oxygen (O2) therapy. The deficient practice had the potential to place R77 and R29 at risk of respiratory complications and unmet needs.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure laboratory tests were conducted in accordance with professional standards for one of 53 sampled residents (R) (R70). This deficient practice had the potential to place R70 at risk of medical complications, unmet needs, and a diminished quality of life.
January 30, 2024Complaint inspection · 2 citations
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, staff interviews, record reviews, and a review of the facility policy titled Person-Centered Medication Administration Schedule, the facility failed to ensure the medication error rate was less than 5%. A total of 34 opportunities were observed with four errors for two residents (R13 and R15), resulting in an error rate of 11.7%. This failure had the potential to result in medication not being given in accordance with the physician's orders and had the potential to adversely affect R13 and R15's clinical conditions.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled Person-Centered Medication Administration Schedule, and Ordering & Receiving Medications, the facility failed to ensure that two of 16 sampled residents (R) (R13 and R15) were free from significant medication errors by not ensuring medications were reordered on time. This failure placed R13 and R15 at risk for decreased therapeutic effects of medications and posed health risks.
March 16, 2023Standard inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interviews, record review, review of the facility policy titled, Abuse & Neglect Prohibition, the facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency (SSA) for one of four residents (R) (#96) reviewed related to abuse.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observations, staff interviews record review, and review of facility's policy titled, Central Vascular Access Device (CVAD) Dressing Change, the facility failed to change the Peripherally Inserted Central Catheter (PICC) Line dressing in timely manner for one of 24 sampled resident (R#64).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that psychotropic medications, specifically a hypnotic, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (#82) reviewed for unnecessary medications.
October 6, 2021Standard inspection · 2 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on record review and staff interviews the facility failed to ensure that the staff designated as the Dietary Manager (DM) was certified or had a similar food service management certification or degree. The deficient practice had the potential to affect 87 of 98 residents who received an oral diet.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interviews, and review on the service manual from the manufacturer the facility failed to ensure the filter for the oxygen concentrator for one of 24 residents, that received respiratory treatment, (R#36) was cleaned and/or changed.
Fire safety inspections
26 fire safety citations on file: 7 on April 16, 2025, 18 on March 16, 2023, 1 on October 6, 2021.
Every fire safety citation26 citations
- F
Provide properly protected cooking facilities.
K 324 · April 16, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · April 16, 2025 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 16, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 16, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 16, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 16, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 6, 2021 · Corrected (the home has a date of correction)