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
9D
1E
0F
Potential for minimal harm
0A
0B
0C
August 28, 2025Standard inspection · 4 citations
- 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 upon observations, the facility failed to ensure residents had a clean and sanitary environment as evidenced by residents' personal items not labeled and stored appropriately for each resident in 5 out of 9 rooms sampled.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, record reviews, and policy review, the facility failed to ensure the provision of care in accordance with professional standards by not ensuring that wound care was provided as stated in the physician order in a timely manner and failed to assess and document a newly identified skin impairment for 2 of 2 residents sampled for non-pressure related skin impairments. (Resident #9 and #106)
- 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 and interview, the facility failed to maintain sanitary food practices and ensure kitchen staff wore required hair covering while preparing resident meals.
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observations and staff interviews, the facility failed to ensure each resident bedroom was equipped to provide full visual privacy for 1 of 19 sampled resident bedrooms. (room [ROOM NUMBER])An observation of room [ROOM NUMBER]A was conducted on 8/26/25 at 2:09 PM. The room was occupied by a resident. The privacy curtain was observed to be about 3 feet too short in width to provide full visual privacy of the resident. In addition, the existing curtain was stuck and would not pull in the curtain track. Another observation of room [ROOM NUMBER]A was conducted on 8/27/25 at 10:07 AM with the Housekeeping Supervisor. She observed the curtain and stated the track was coming loose from the ceiling and confirmed the curtain was too short in length to provide full visual privacy. [...]
June 6, 2024Standard inspection · 5 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, staff interview, resident interview, and records review, the facility failed to ensure the interdisciplinary team assessed and determined residents were capable of self-administration of medications prior to allowing 2 of 4 residents sampled for medication administration to self-administer medications. (Residents #32 and #61)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure that wound assessments, dressing changes and wound care were provided in accordance with physician orders and facility policy for 2 of 3 residents sampled for wound care observations (Resident #7 & #24).
- 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 follow physician orders for tube feeding formula for 1 of 1 resident reviewed for tube feeding. (Resident #26)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, interviews, and policy review, the facility failed to obtain physician orders to administer oxygen for 1 of 4 residents sampled for respiratory care. (Resident #15)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control protocol for 1 of 1 resident reviewed for transmission based precautions. (Resident #44)
March 16, 2023Standard inspection · 1 citation
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interviews, record reviews and policy reviews, the facility failed to ensure accurate accounting of controlled substances for 3 of 7 residents sampled (Residents #20, #57, and #155).
Fire safety inspections
13 fire safety citations on file: 1 on August 28, 2025, 4 on June 6, 2024, 8 on March 16, 2023.
Every fire safety citation13 citations
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 6, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 16, 2023 · Corrected (the home has a date of correction)