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
7D
11E
1F
Potential for minimal harm
0A
0B
0C
December 18, 2025Standard inspection, Complaint inspection · 7 citations
- F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on record review and interview, the facility failed to ensure 18 of 18 dietary contract employees received abuse training. The DON identified 141 residents resided in the facility.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure:a. walls and paint were in good repair for 2 (#3 and #6), and b. a resident's bed was in good repair for 1 (#3) of 28 sampled residents reviewed for a safe home like environment. The DON identified 141 residents resided in the facility.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy by not ensuring all staff working in the facility were trained on identifying and reporting abuse for 18 of 18 dietary contractor staff members. The DON identified 141 residents resided in the facility.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure there were enough trained staff at set meal times for 4 of 4 dining observations. The DON identified 138 residents received nutrition from the kitchen.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure:a. prepared food items were labelled with the preparation and use-by dates,b. food items were discarded after the expiration date,c. fresh food items with visible mold, discoloration, or soft to touch were discarded,d. opened food items were stored in airtight packaging,e. monitoring of temperatures for refrigerators and freezers containing food, andf. food was prepared in a sanitary environment for 2 of 2 kitchen observations. The DON identified 138 residents received nutrition from the kitchen.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bathrooms accessible to residents had call lights for 2 of 2 bathrooms observed accessible to residents. The DON identified 141 residents resided in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to handle and process linens to prevent the spread of infection for residents on contact isolation in the laundry room. The infection preventionist identified five residents on contact precautions.
September 11, 2025Complaint inspection · 1 citation
- 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, record review, and interview, the facility failed to develop a comprehensive care plan intervention for transfers for 2 (#12 and #13) of 3 sampled residents reviewed for care plans. The DON identified 152 residents resided in the facility.
June 5, 2024Standard inspection · 6 citations
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to administer O2 according to physician orders and/or label O2 tubing for two (#13 and #54) of three sampled residents reviewed for respiratory care. The DON identified 29 residents received O2.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review and interview, the facility failed to complete ongoing assessments of a resident pre and post dialysis for one (#67) of one resident reviewed for dialysis services.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. staff used personal protective equipment and sanitized a blood pressure cuff for a resident with contact precautions for one (#93) of two sampled residents reviewed for transmission based precautions; b. staff used personal protective equipment for a resident with enhanced barrier precautions for one (#56) of one enhanced barrier precaution observation; and c. staff maintain infection control practices during incontinent care for one (#52) of seven incontinent care observation. The infection preventionist identified eight residents who were on transmission based precautions and 31 residents who were on enhanced barrier precautions resided in the facility. The DON identified 45 residents required assistance with incontinent care.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide double portions as ordered for one (#52) of three residents observed for meal service. The DON identified 143 residents received meal service from the kitchen.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an enteral tube feeding bottle was properly labeled for one (#54) of two sampled residents reviewed for tube feeding management. The DON identified three residents received enteral tube feeding via continuous pump.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for one (#24) of three sampled residents reviewed for respiratory care. The DON identified 148 residents resided in the facility.
April 28, 2023Standard inspection · 5 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure: a. physician orders were in place for wound care and dressing changes, b. a surgical wound was assessed and monitored, and c. a resident was monitored as ordered for side effects related to a medication error for one (#269) of three sampled residents reviewed for wound care and medication errors. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility. The ADON identified four residents with surgical wounds.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for three (#62, 70 and #269) of three sampled residents reviewed for medication errors. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to: A. ensure hands were washed/sanitized during resident medication pass for two (#13 and #53) of two sampled resident observed during medication pass, and B. provide wound care in a manner which prevented cross contamination for one (#222) of one sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 04/24/23, reported 143 residents resided in facility and 16 of those residents had pressure ulcers. Findings A Dressings policy, revised 09/13, read in parts, .Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area . 1. On 04/25/23 at 3:28 p.m., CMA #1 was observed administering oral medications to resident #13. [...]
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the choice to formulate advance directives and a code status had been determined for one (#15) of 32 sampled residents reviewed for advanced directives and code status. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility.
- D
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on record review and interview the facility failed to ensure (CMA #5) had completed a clinical skills check prior to passing medications for one (#269) of three sampled residents reviewed for medication errors. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility.
Fire safety inspections
8 fire safety citations on file: 1 on June 5, 2024, 3 on April 28, 2023, 4 on February 22, 2022.
Every fire safety citation8 citations
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · June 5, 2024 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · April 28, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 28, 2023 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · April 28, 2023 · 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 · February 22, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 22, 2022 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · February 22, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 22, 2022 · Corrected (the home has a date of correction)