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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
0E
0F
Potential for minimal harm
0A
0B
0C
January 8, 2026Standard inspection · 6 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, resident interview, staff interview, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined if a resident was capable of self-administration of medications prior to allowing the practice for 4 of 25 sampled residents. (Resident #43, #112, #67 and #7)
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure the long term care ombudsman received a copy of the transfer notice for 1 of 2 residents reviewed for hospitalization. (Resident #156)
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures, the facility failed to ensure each resident requiring a Preadmission Screening and Resident Review (PASARR) Level II screening had the evaluation completed for 1 of 1 residents sampled. (Resident #122)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased upon interviews, observations, and record review, the facility failed to provide activities of daily care who is dependent for care and services for 1 of 5 residents reviewed. (Resident #115)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record, and policy review, the facility failed to ensure that residents received wound care and treatment in accordance with professional standards of practice in 1 of 1 resident sampled for wound care. (Resident #122)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased upon observation, record review, and interviews the facility failed to demonstrate an infection prevention and control program that identifies, investigates and monitors all infections at the facility. Additionally, the facility failed to follow hand hygiene procedures when initiating intravenous medication administration for 1 of 1 residents reviewed. (Resident #7)
August 29, 2024Standard inspection · 2 citations
- 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 observations, interviews, and record review, the facility failed to follow physician orders for tube feeding start time and formulary for 1 of 2 residents reviewed for tube feeding. (Resident #5)
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to properly offer and document influenza, pneumococcal, and COVID-19 vaccinations for 3 of 5 residents reviewed for vaccination status. (Resident #43, 100, and 326)
July 1, 2024Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to procure physician's orders for 1 of 3 residents reviewed for Continuous Positive Airway Pressure (CPAP) use. (Resident #1)
April 30, 2024Complaint inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interviews, the facility failed to provide treatment to a pressure ulcer upon admission to the facility for 1 of 3 residents sampled (Resident #1).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to ensure that wound care documentation was completed for 2 of 3 residents sampled for wound care (Resident #2 and #3).
June 22, 2023Standard 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 observations, interviews, and electronic record reviews, the facility failed to follow the care plan for 1 of 1 residents sampled for positioning and mobility. (Resident #40)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that pain management was provided to 2 of 2 residents reviewed, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. (Residents #202 and #83).
Fire safety inspections
10 fire safety citations on file: 4 on January 8, 2026, 6 on August 29, 2024.
Every fire safety citation10 citations
- D
Establish staff and initial training requirements.
E 37 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 29, 2024 · 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 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · August 29, 2024 · Corrected (the home has a date of correction)