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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
2E
4F
Potential for minimal harm
0A
0B
0C
November 17, 2025Standard inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observations, and interviews, the facility failed to ensure two dietary aides had a protective facial hair covering while working in the kitchen, failed to ensure food items were properly labeled (name, date opened, or expiration date), failed to ensure frozen food items were stored at a temperature for frozen food items to remain frozen solid which had the potential to affect 71 of 72 residents, and failed to ensure an expired nutritional supplement was discarded and unavailable for resident use on 1 of 2 medication carts observed.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure 1 resident (Resident #19) was treated with dignity during feeding assistance of 7 residents observed for dining.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on review of facility policy, review of medical record, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) after the resident was admitted to the facility with a mental health diagnosis for 1 resident (Resident #11) of 8 residents reviewed for PASRR.
- D
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 review of the facility policy, record review, observations and interviews, the facility failed to develop a comprehensive person-centered care plan for 1 resident (Resident #82) of 19 residents reviewed for care plans.
- D
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 review of the facility policy, review of manufacturer guidelines, medical record review, observations, and interviews the facility failed to ensure insulin medication was labeled appropriately to include an open date for 2 residents (Resident #46 and Resident #23) and failed to ensure eye medication was labeled appropriately to include an open date for 1 resident (Resident #67) of 3 residents reviewed for medication administration on 1 medication cart of 2 medication carts observed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the facility policy, medical record review, observations and interviews the facility failed to ensure staff followed infection control guidelines during wound care for 1 resident (Resident #44) of 3 residents reviewed for wounds.
June 28, 2022Standard inspection · 10 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of the Facility Assessment, review of facility's daily staffing sheets, review of facility shower schedules, medical record review, and interview, the facility failed to provide adequate staffing on the weekends to meet the needs of residents in the facility for 2 months (May and June 2022), which had the potential to affect all residents in the facility.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to properly store frozen foods in 1 of 1 freezer, failed to date 3 containers of dried foods in the kitchen area, and failed to maintain proper temperatures in 2 of 2 nourishment refrigerators, potentially affecting 58 of 60 residents in the facility.
- 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 review of the facility policy, medical record review, observation, and interview, the facility failed to develop a comprehensive care plan to include a urinary catheter for 1 resident (Resident #12), to include Activities of Daily Living (ADL) for bathing for 4 residents (Residents #14, #29, #52, and #210), and to include use of psychotropic medications for 1 resident (Resident #35) of 20 residents reviewed for care plans.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on facility policy review, medical record review, facility shower schedule review, and interview, the facility failed to provide scheduled showers for 4 residents (Residents #14, #29, #52, and #160) of 10 residents reviewed for showers.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a comprehensive resident admission assessment within 14 calendar days after admission for 1 resident (Resident #1) of 20 residents reviewed.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to develop a baseline care plan to include the use of psychotropic medications for 1 resident (Resident #160) of 5 residents reviewed for unnecessary medications.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician's order for wound treatment for 1 resident (Resident #10) of 4 residents reviewed for wounds.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician's order for an oral nutritional supplement for weight loss for 1 resident (Resident #37) of 3 residents reviewed for weight loss.
- 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 facility policy review, medical record review, pharmacy recommendation review, and interview, the facility failed to act timely on a pharmacy recommendation for 1 resident (Resident #8) of 5 residents reviewed for unnecessary medications.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on facility policy review, medical record review, pharmacy recommendation review, and interview, the facility failed to provide a gradual dose reduction per pharmacist recommendation for 1 resident (Resident #8) of 5 residents reviewed for unnecessary medications.
October 22, 2019Standard inspection · 7 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to store cooking/serving utensils in a sanitary manner, failed to properly air dry 6 pans of approximately 15 pans observed, and failed to ensure expired foods were not available for resident use potentially affecting 64 of 65 residents.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to accurately assess and document a Stage 2 pressure ulcer for 1 resident (#5) of 29 residents reviewed.
- 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 facility policy review, medical record review, review of facility documentation, and interview, the facility failed to revise a care plan for 1 resident (#50) of 29 residents reviewed.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on medical record review and interview, the facility failed to ensure vision services were provided for 1 resident (#23) of 16 residents reviewed for vision.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure dental services were provided for 1 resident (#23) of 29 residents sampled.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to maintain an accurate medical record for 1 resident (#48) of 11 residents reviewed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to follow infection control guidelines during a wound observation for 1 resident (#5) of 3 wound observations.
Fire safety inspections
20 fire safety citations on file: 6 on November 17, 2025, 7 on June 28, 2022, 7 on October 22, 2019.
Every fire safety citation20 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · June 28, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 28, 2022 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · June 28, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 28, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 28, 2022 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · June 28, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · June 28, 2022 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · October 22, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 22, 2019 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 22, 2019 · 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 22, 2019 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · October 22, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · October 22, 2019 · Corrected (the home has a date of correction)