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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
0E
0F
Potential for minimal harm
0A
0B
0C
July 23, 2026Standard inspection · 3 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 observation, interviews, record review, and review of facility policy, the facility failed to implement care planned interventions to address dining needs for Resident #65. This affected one (Resident #65) resident of 20 residents reviewed for care plans. The facility census was 61.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to obtain weekly weights for Resident #14 who was at nutritional risk for weight loss. This affected one (Resident #14) of five residents reviewed for nutrition. The facility identified 11 residents (Resident #14, #12, #18, #8, #30, #31, #72, #36, #71, #42, and #10) with physician orders for weekly weights. The facility census was 61.
- 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 observation, interviews, record review and review of facility policy, the facility failed to ensure medications were properly stored and secured. This affected two Residents (#4 and #59) out of 17 residents observed for medication storage. The facility had a total census of 61.
November 25, 2025Complaint inspection · 3 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and review of facility policy revealed the facility did not ensure pressure ulcer injuries were assessed and documented timely and accurately when identified. This affected one Resident (#64) out of three residents reviewed for pressure ulcers. This had the potential to affect seven Residents (#8, #9, #10 #14, #18, #29, and #43) the facility identified with pressure ulcers. The facility census was 63. Findings Include:Review of closed medical record for Resident #64 revealed an admission date of 07/10/25 and she was discharged home with home health on 08/19/25. She later readmitted back to the facility on [DATE] and then was sent to the hospital on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm of breast, malignant neoplasm of lung, malignant neoplasm of the bone, and hypertension. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and facility staff interview the facility failed to ensure the medical record was accurate. This affected one, Resident #64, of three reviewed for wounds. The facility census was 63. Findings Include:Review of closed medical record for Resident #64 revealed an admission date of 07/10/25 and she was discharged home with home health on 08/19/25. She later readmitted back to the facility on [DATE] and then was sent to the hospital on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm of breast, malignant neoplasm of lung, malignant neoplasm of the bone, and hypertension. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition and had impairment on one of her lower extremities. She was dependent of staff assistance with toileting, putting on footwear, and dressing. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, observation, record review, and review of facility policy, the facility failed to ensure proper infection control measures were maintained during tracheostomy (a surgical opening in the neck to provide direct airway into the windpipe) care. This affected one Resident (#53) out of one resident observed for tracheostomy care. This had the potential to affect 11 Resident (#2, #4, #9, #10, #21, #38, #43, #48, #53, #59, and #66) identified by the facility with tracheostomies. The facility census was 63.
July 8, 2024Standard inspection · 3 citations
- 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, interview, record review, and review of facility policy the facility did not ensure range of motion (ROM) restorative nursing programs were completed for Residents #11 and #43 as ordered. This affected two residents (#11 and #43) of two residents reviewed for ROM. This had the potential to affect 48 residents (#1, #2, #3, #4, #5, #6, #7, #10, #11, #13, #15, #17, #19, #18, #20, #21, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #50, #52, #53, #54, #56, #58, #59, and #120) identified on a restorative ROM program. The facility census was 64.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide adequate tracheostomy care including timely respiratory evaluations as ordered for Resident #45. This affected one resident (#45) of four residents reviewed for tracheostomy care. The facility identified 11 residents (#15, #22, #38, #45, #47, #51, #54, #55, #57, #118 and #119) with tracheostomies. The facility census was 66.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, record review, and review of facility policy revealed the facility did not ensure Resident #13 was free of significant medication error. This affected one resident (#13) out of seven residents reviewed for medication administration. The facility census was 64.
May 12, 2022Standard inspection · 1 citation
- 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 record review and interview the facility failed to ensure one resident (Resident #17) received restorative range of motion (ROM) and ambulation programs per the plan of care. This affected one (Resident #17) of two residents (Residents #1 and #17) reviewed for restorative nursing and had the potential to affect all 54 (Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #20, #21, #22, #23, #25, #26, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #57, #58, #60, #63, #64, #66, #319 and #320) residents with planned restorative nursing programs. The facility census was 65.
Fire safety inspections
6 fire safety citations on file: 1 on July 23, 2026, 4 on July 8, 2024, 1 on May 12, 2022.
Every fire safety citation6 citations
- E
Install an approved automatic sprinkler system.
K 351 · July 23, 2026 · deficient, provider has
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · July 8, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 8, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 8, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · July 8, 2024 · 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 · May 12, 2022 · Corrected (the home has a date of correction)