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
5D
6E
0F
Potential for minimal harm
0A
3B
0C
January 7, 2026Standard inspection · 8 citations
- E
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 record reviews, the facility failed to ensure a resident's care plan was developed to reflect the current needs of the resident for 2 of 16 residents reviewed for care planning (Resident #3, #35).
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure foods were labeled and dated in the reach in refrigerator for 2 of 2 kitchen tours. (1/5/26 and 1/5/26)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). In addition, facility failed to demonstrate staff competency for Infection Control in the areas of TBP and EBP in 2 of 2 units (Periwinkle and hummingbird).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations and interviews, the facility failed to provide care for a resident in a dignified manner when a Certified Nursing Assistant (CNA#1) was observed transporting a resident in a shower chair when a resident wasn't provided a cover in a dignified manner exposing their bottom in a facility hallway (Resident #3).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record reviews and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed for care planning (Resident #35).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of medication administration and treatments for 2 of 19 sampled residents (Residents #35 and #2).1. On 1/6/26 at 11:56 a.m. observed Registered Nurse (RN#3) push the medication cart to R#2's room, proceeded to pull the medications out of the cart and then crushed them without verifying the medications to the resident's chart. The surveyor questioned the practice, but RN#3 stated she did it by memory and that the order is on the resident's Treatment Administration Record (TAR). Even after surveyor intervention RN#3 did not review the TAR before giving the resident the medications. On 1/6/26 at 12:00 p.m. the above finding was confirmed with RN#3. 2. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 residents reviewed for respiratory care (Residents #24, #35, and #41). In addition, the facility failed to ensure physician orders were obtained and provided proper monitoring for 1 of 5 residents (Resident #6) receiving oxygen therapy and failed to ensure that physician orders were followed for 1 of 4 residents (Resident #24) receiving oxygen therapy.2. On 1/5/26 at 9:33 a.m. and on 1/6/26 at 8:14 a.m. a surveyor observed the following: Resident #24 seated in his/her recliner chair, wearing nasal cannula (NC) oxygen tubing, dated 1/3/26, with the oxygen concentrator set to 2.5 liters per minute (L/min). [...]
- B
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 interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for positioning and mobility (Resident #3).
October 23, 2024Standard inspection · 4 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards, as is possible, related to a patient lift on 2 of 2 units (Periwinkle and Hummingbird) and for 1 of 3 days of survey. (10/21/24)
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, facility policy, record review and interviews the facility failed to adequately ensure medications were monitored and stored at appropriate temperatures in 1 of 1 refrigerator observed.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interviews and record review, the facility failed to provide specialized rehabilitative services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services for 1 of 2 residents reviewed for rehabilitative services. (#43)
- B
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 facility policy, interviews, record review, the facility failed to label resident's personal belongings and keep them safe and secure for 2 of 3 residents reviewed for personal property. (Resident #15 and #34)
August 9, 2023Standard 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 observation, interview, and the facility's Food Receiving and Storage Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, the surrounding ceiling, and a food disposal unit. Additionally, the facility failed to ensure foods were dated and labeled in the walk-in refrigerator and the walk-in freezer for 1 of 1 tour.
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and unlicensed nursing staff responsible for direct resident care in a prominent place readily accessible to residents and visitors for 2 of 3 survey days. (8/7/23 and 8/8/23)
Fire safety inspections
9 fire safety citations on file: 5 on January 7, 2026, 3 on October 23, 2024, 1 on August 9, 2023.
Every fire safety citation9 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · January 7, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 7, 2026 · 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 · January 7, 2026 · Corrected (the home has a date of correction)
- D
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · January 7, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 7, 2026 · Corrected (the home has a date of correction)
- D
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 23, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 23, 2024 · Corrected (the home has a date of correction)
- C
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · October 23, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 9, 2023 · Corrected (the home has a date of correction)