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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
1L
Actual harm
3G
0H
0I
Potential for more than minimal harm
9D
0E
3F
Potential for minimal harm
0A
0B
0C
July 8, 2026Complaint inspection · 3 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide professional standards of care for an arm injury/laceration. The facility failed to adequately assess the degree of the injury/laceration, thoroughly document the injury/laceration, and provide necessary wound care. R1 was sent to the emergency room for a large laceration with bone and tendon exposed to R1's left arm. This failure applies to 1 of 3 residents (R1) reviewed for quality of care.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to timely report an injury of unknown origin to the state surveying agency. This failure applies to 1 of 3 residents (R1) reviewed for reporting alleged violations.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately investigate an injury of unknown origin after it was identified. This failure applies to 1 of 3 residents (R1) reviewed for investigating alleged violations.
May 9, 2025Standard inspection · 5 citations
- F
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 maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 22 residents in the facility receiving dietary services.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or their representatives written notification of the reason for transfer to the hospital and failed to notify the ombudsman of the hospital transfer. This applies to 2 of 2 residents (R15 and R21) reviewed for discharge in a sample of 14.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement dietician-recommended interventions for resident with significant weight loss. This applies to 1 resident (R13) reviewed for weight loss in a sample of 14 residents.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow the physician order to administer intravenous (IV) antibiotics. This applies to 1 of 1 resident reviewed (R225) for IV antibiotics in a sample of 14.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during high contact resident care activities and failed to perform hand hygiene during incontinent care. This applies to 3 of 3 residents (R6, R13, and R225) in a sample of 14.
January 7, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of potential abuse and report it the State Agency within the timeframes. This applies to 1 of 1 resident (R1) reviewed for abuse.
May 21, 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 observation, interview, and record review the facility failed to notify the physician of the inability to complete ordered testing timely. This applies to 1 of 4 residents (R1) reviewed for physician ordered testing in a sample of 4.
April 26, 2024Standard inspection · 1 citation
- F
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 properly label and date refrigerated items and remove expired food items in the kitchen. This applies to all 16 residents that receive oral nutrition and foods prepared in the facility kitchen.
November 20, 2023Complaint inspection · 3 citations
- L
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on interview and record review the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R2) with full code status. The facility also failed to have a system in place to ensure that Advance Directives were accurate and complete (R1, R5, R11, R12). These failures resulted in R2 not receiving CPR as desired; and R1 being sent to the hospital, intubated, and later compassionately extubated at the hospital. These failures have the potential to affect all 22 residents residing in the facility.
- G
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 interview and record review the facility failed to notify the physician of a resident's change of condition. This applies to 1 of 12 residents (R2) reviewed for advanced directives in a sample of 14. This failure resulted in a potentially avoidable death when R2's change in condition was not addressed and R2 expired unexpectedly.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to keep a resident free from neglect when they failed to notify the physician of a change in condition, provide medications as ordered, and initiate cardiopulmonary resuscitation. This applies to 1 of 12 residents (R2) reviewed for advanced directives in a sample of 14. This failure resulted in a potentially avoidable death when R2's change in condition was not addressed. R2 was later observed unresponsive and resuscitation and/or emergency interventions were not initiated.
March 31, 2023Standard inspection · 2 citations
- F
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 food items in a sanitary condition. This affects all 22 residents consuming food from the kitchen.
- D
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 observation, interview, and record review, the facility failed to provide catheter care to prevent potential urinary tract infection (UTI) by having the catheter bag touching the floor, not maintaining the catheter bag below bladder level, and not maintaining a closed system of the indwelling catheter. This applies to 1 of 2 residents (R18) reviewed for indwelling catheter care in a sample of 14.
Fire safety inspections
10 fire safety citations on file: 4 on May 9, 2025, 3 on April 26, 2024, 3 on March 31, 2023.
Every fire safety citation10 citations
- 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 9, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 9, 2025 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · May 9, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 9, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 26, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 31, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 31, 2023 · Corrected (the home has a date of correction)