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 14 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
4E
0F
Potential for minimal harm
0A
0B
0C
August 7, 2025Standard inspection · 5 citations
- E
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 ensure insulin was administered as ordered by physician for 4 of 8 residents reviewed for unnecessary medications (Residents #1, #183, #72, and #102), and failed to ensure hypotensive medication was administered as per the parameters ordered by physician for 1 of 8 residents reviewed (Resident #27).
- 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, interview, and record review, the facility failed to ensure proper positioning while tube feeding for 1 of 2 residents reviewed for tube feeding (Resident #40).
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented the rationale for disagreement with the pharmacist's recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident #58).
- 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 interview, the facility failed to ensure medical records were complete and accurate for antidiabetic medication administration for 1 of 8 residents reviewed for medication management (Resident #34).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident #192) was placed on contact precautions and failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene while providing care to the residents on contact precautions to prevent the possible spread of infection and communicable diseases.
May 2, 2024Standard inspection · 6 citations
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) was accurate for 2 of 3 residents reviewed for discharge, Residents #174 and #175.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received oxygen as per physician order for 2 of 3 residents reviewed for respiratory care, Residents #139, and #154.
- D
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, interview, and record review, the facility failed to ensure residents had a safe and homelike environment in 2 of 3 residential units, 200 Unit and 300 Unit (Photographic evidence obtained).
- 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 ensure residents received appropriate urinary catheter care, and failed to ensure urinary flow into the urinary catheter bag was maintained for 1 of 3 residents reviewed for incontinence care, Resident #165.
- D
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 ensure foods were stored in a safe and sanitary manner in the main kitchen of the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration and failed to ensure staff followed infection control standards of practice for administration of subcutaneous medications to help prevent the possible transmission of infection and communicable diseases.
January 6, 2023Standard inspection · 3 citations
- 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, interview, and record review, the facility failed to ensure foods in the refrigerator/freezer were covered, dated, labeled, and shelved to allow circulation, failed to ensure the equipment was in good condition, and failed to ensure the kitchen and food service equipment were clean.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 3 sampled residents, Resident #32.
- D
Provide and implement an infection prevention and control program.
Inspectors wrote2. Review of the medical records for Resident #32 revealed the resident was admitted on [DATE] with the diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, immobility syndrome, unspecified severe protein calorie malnutrition, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere, chronic obstructive pulmonary disease, emphysema, pressure ulcer of sacral region, stage 4 pressure ulcer of left hip, other lack of coordination, dislocation of thoracic 12 lumbar 1 vertebra sequela, paraplegia, polyneuropathy, neuromuscular dysfunction, hyperlipidemia, anemia, other injury of unspecified body region, sepsis due to methicillin resistant staphylococcus aureus, obstructive and reflux uropathy, colostomy, resistance to multiple antibiotics, stage 4 pressure ulcer of left [...]
Fire safety inspections
2 fire safety citations on file: 1 on August 7, 2025, 1 on January 6, 2023.
Every fire safety citation2 citations
- E
Install an approved automatic sprinkler system.
K 351 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 6, 2023 · Corrected (the home has a date of correction)