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 12 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
1E
1F
Potential for minimal harm
0A
0B
0C
January 29, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, review of camera video footage and facility policy review, the facility failed to ensure Resident #41 had appropriate transmission-based precautions implemented. This affected one (Resident #41) out of three residents reviewed for infection control. The facility census was 62.
June 26, 2025Standard inspection · 2 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure accurate weights were obtained for Resident #31 and Resident #46. This affected two (Residents #31 and #46) of six residents reviewed for nutrition. The facility census was 62.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #162 had a physician's order for oxygen. This affected one (Resident #162) out of one resident reviewed for respiratory care. This had the potential to affect 18 (Residents #2, #4, #7, #10, #12, #17, #18, #28, #32, #39, #40, #44, #46, #48, #53, #113, #166, and #168) identified by the facility on oxygen. The facility census was 62.
May 22, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to use appropriate infection control precautions while providing wound care to Resident #50 who was in enhanced barrier precautions. This affected one Resident #50 but had the potential to affect all 29 residents who were ordered enhanced barrier precautions, Residents #5, #8, #9, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #30, #31, #33, #36, #37, #40, #44, #46, #50, #58, #61, #63, and #64. The facility census was 64.
February 6, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, facility policy review, and interview the facility failed to ensure Resident #24's left foot was assessed after State Tested Nursing Assistant (STNA) #610 bumped her foot on her bedroom doorframe, failed to complete documentation of the incident, and failed to ensure the physician was notified timely. This affected one resident (#24) of three residents reviewed for injuries. The facility census was 51.
December 11, 2023Complaint inspection · 3 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, record review, review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, and review of the facility policy the facility failed to ensure Resident #2 was able to be transferred from his bed to a padded wheelchair using a mechanical lift when he requested the transfer. This affected one resident (#2) out of three residents reviewed for transfers. The facility census was 55.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, closed record review, review of the facility policy and review of the Centers for Medicare and Medicaid Services (CMS) guidance the facility failed to ensure Resident #56's eye infection was treated while she resided in the facility. This affected one resident (#56) out of three residents reviewed for infections. The facility census was 55.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, closed record review, and review of the facility policy the facility failed to thoroughly document the appearance of Resident #56's bilateral heel deep tissue injuries (DTI). This affected one resident (#56) out of three residents reviewed for pressure ulcer injuries. The facility census was 55.
July 24, 2023Standard inspection · 2 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure meals served looked appetizing and were served at palatable temperatures. This had the potential to affect all residents receiving meals from the kitchen with the exception of Residents #1 and #10 who received no nutrition by mouth. The facility census was 49.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure proper hand hygiene was completed during medication administration including hand washing and wearing gloves. This affected three Residents (Residents #4, #32, and #101) out of seven residents administered medications. The facility census was 49.
January 23, 2020Standard inspection · 2 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 record review, observation and interviews the facility failed to store foods brought in from outside the facility for the residents were under sanitary and safe conditions. This had the potential to affect all 38 residents ( #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#12,#13,#15,#16,#17,#18,#19,#20,#21,#22,#23,#24,#25,#26,#28,#29,#31,#32,#33,#34,#35,#37,#39,#41,#43,#44,#48,#203) and also affected Resident #204 residing on the Walnut and Maple units in the facility. The facility census was 56.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review, observation and interviews the facility failed to ensure Resident #40 received adequate pain management when routine pain medication was not given per a physician order. This affected one of three residents reviewed for pain (Resident #40). The facility census was 56.
Fire safety inspections
16 fire safety citations on file: 11 on June 26, 2025, 4 on July 24, 2023, 1 on January 23, 2020.
Every fire safety citation16 citations
- F
Include a process for Emergency Preparedness collaboration.
E 9 · June 26, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 26, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 26, 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 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · June 26, 2025 · 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 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 26, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 26, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 24, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 24, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 24, 2023 · 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, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 23, 2020 · Corrected (the home has a date of correction)