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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
1E
0F
Potential for minimal harm
0A
0B
0C
October 1, 2025Standard inspection · 2 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interview and record review, the facility did not ensure daily weights were consistently completed or a physician was notified of a significant weight gain for 1 resident (R) (R67) of 6 sampled residents. R67 had a diagnosis of congestive heart failure (CHF). R67 had an order for daily weights and to notify the physician of a weight gain of 3 pounds (lbs) or more in one day. R67 had a significant weight gain of 7.4 lbs (5.96%) from 9/19/25 to 9/20/25. Staff did not consistently complete daily weights or notify the physician of R67's weight gain.
- 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, staff interview, and record review, the facility did not provide services to prevent complications of enteral feeding for 1 resident (R) (R42) of 1 sampled resident with a feeding tube. R42 received medication, nutritional supplements, and hydration via gastrostomy (G)-tube. During an observation of medication administration, Licensed Practical Nurse (LPN)-D did not flush R42's G-tube with 10 cubic centimeters (ccs) of water between medications as ordered.
July 7, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and record review, the facility did not ensure a medical record contained complete and accurate information for 1 resident (R) (R5) of 10 sampled residents. On 6/28/25, Registered Nurse (RN)-C assessed R5 for stroke symptoms after receiving a concern from R5's friend. RN-C did not document the neurological assessment in R5's medical record after it was completed.
November 26, 2024Complaint inspection · 3 citations
- 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, staff interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 2 residents (R) (R13 and R14) of 10 sampled residents. On 11/26/24, R13 and R14's catheter drainage bags were observed on the floor.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not follow a prescribed individualized diet to ensure nutritional needs were met for 1 resident (R) (R11) of 8 sampled residents. During the 11/26/24 lunch meal, staff did not follow R11's consistent carbohydrate (CCHO) diet order.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R8) of 14 residents observed during the provision of care. In addition, dietary staff touched items in the kitchen without completing hand hygiene. R8 was on enhanced barrier precautions (EBP) which required staff to wear personal protective equipment (PPE) during high-contact care. On 11/26/24, staff transferred R8 without wearing PPE. On 11/26/24, Dietary Aide (DA)-L lifted a garbage can lid with gloved hands. DA-L then wrapped food and touched items in the kitchen without completing hand hygiene.
July 24, 2024Standard 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 and staff interview, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 60 of 105 residents residing in the facility. On 7/23/24 and 7/24/24, beverages were not iced during meal service. The temperature of the milk at the end of meal service on 7/23/24 was 59 degrees Fahrenheit (F). Resident food was not heated in a microwave according to regulations or the facility's policy.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent a pressure injury from developing and/or promote healing for 1 resident (R) (R161) of 5 sampled residents. R161 had a history of a stage 2 pressure injury on the sacral/coccyx area. R161's skin integrity care plan contained an intervention for a pressure reducing cushion while up in chair. During an observation on 7/24/24, R161 did not have a cushion in R161's recliner.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 25 opportunities which resulted in an 8% medication error rate that affected 1 resident (R) (R18) of 12 residents observed during medication pass. On 7/22/24, R18 was administered an incorrect dose of two eye drops.
September 27, 2023Complaint inspection · 5 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on staff and resident interview and record review, the facility failed to protect residents' rights to be free from sexual abuse when they determined 2 cognitively impaired Residents (R) (R1 and R5) of 5 sampled residents engaged in a sexual act despite interviews that indicated R1 and R5 did not want a sexual relationship with each other. The facility was aware R1 had a history of exposing R1's genitals when R1 was admitted to the facility on [DATE]. Staff was also aware that approximately two months prior to 9/5/23 (date unknown), staff reported R1 and R5 were observed in R1's room with R1's brief and pants down, and R1's genitals exposed. The facility provided an undated and incomplete investigation that indicated R5 was helping R1 with R1's pants. There was no assessment of either resident's ability to consent to a sexual relationship. [...]
- 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 staff and provider interview, and record review, the facility did not promptly notify the provider and/or Power of Attorney for Healthcare (POAHC) of a change in condition for 2 Residents (R) (R1 and R5) of 2 residents. R1's provider was not notified timely of an increase in R1's sexual behaviors and a sexual encounter between R1 and R5. R5's POAHC and provider were not notified timely of a sexual encounter between R5 and R1.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act for 2 Residents (R) (R1 and R5) of 5 residents reviewed. R1 and R5 had activated [NAME] of Attorney for Healthcare (POAHC) due to impaired cognition. On 9/5/23, staff observed R1 touching R5's genitals in R5's room behind a closed door. The allegation of sexual abuse was not reported to the SA or law enforcement.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on resident and staff interview, and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 2 Residents (R) (R1 and R5) of 5 residents reviewed. The facility did not complete a thorough investigation regarding an allegation of sexual abuse after R1 and R5 were observed in a sexual encounter behind a closed door in R5's room.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and record review, the facility did not ensure the medical record contained accurate and complete documentation for 2 Residents (R) (R1 and R5) of 5 sampled residents. The medical records for R1 and R5 did not contain complete and accurate documentation related to sexual interactions between R1 and R5.
June 1, 2023Standard inspection · 0 citations
Fire safety inspections
14 fire safety citations on file: 4 on October 1, 2025, 6 on July 24, 2024, 4 on June 1, 2023.
Every fire safety citation14 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 1, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 1, 2025 · 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 · October 1, 2025 · 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 · October 1, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · July 24, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · July 24, 2024 · 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 · July 24, 2024 · 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 · July 24, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 24, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 1, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 1, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · June 1, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 1, 2023 · Corrected (the home has a date of correction)