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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
13D
3E
1F
Potential for minimal harm
0A
0B
1C
December 11, 2025Standard inspection · 4 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 observations, facility policy review and staff interviews, the facility failed to ensure a sanitary dining experience due to not all dietary staff wearing hair nets while plating and serving resident meals. The facility reported a census of 66 residents.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, dining services record review, facility policy review, and staff interviews, the facility failed to document food temperatures before and after service for multiple meals in the memory care unit of the facility. The facility reported a census of 66 residents, with 24 residents on the memory care unit.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on Summary of Deficiency review, facility policy review and staff interviews the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to prevent repeated deficiencies in the area of infection control during the current and previous recertification surveys. The facility reported a census of 66 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, clinical record review and staff interview, the facility failed to implement infection control practices during wound care for 2 of 3 residents reviewed. Enhanced Barrier Precaution (EBP) not utilized during care of a chronic wound (Resident #8), and hand hygiene not completed and equipment not disinfected during the care of pressure wound (Resident #7). The facility reported a census of 66 residents.
October 31, 2024Standard inspection, Complaint inspection · 6 citations
- E
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 observation, resident interview, and staff interview the facility failed to maintain a sanitary, orderly, and comfortable interior in the facility dining room during 4 of 4 dining observations. The facility reported a census of 71 residents.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, facility policy review and staff interview, the facility failed to maintain a proper safe and appetizing food temperatures during a noon meal. The facility reported a census of 71 residents.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review, policy review, and staff interview the facility failed to maintain accurate Advance Directive records based on resident preference for 1 of 18 residents reviewed (Resident #42). The facility reported a census of 71.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the state agency for 1 out of 1 allegation of abuse reviewed (Resident #75). The facility reported a census of 71 residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, staff interview and facility policy review the facility failed to investigate an allegation of abuse for 1 out of 1 residents reviewed (Resident #75). The facility reported a census of 71 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interview the facility failed to utilize Enhanced Barrier Precautions while providing high contact care for 1 of 3 residents with a indwelling medical device (Resident #52), and maintain a foley catheter collection bag and tubing off the floor for 1 of 2 residents (Resident #125). The facility reported a census of 71 residents.
August 30, 2024Complaint inspection · 2 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, facility policy review, staff, and hospice provider interviews, the facility failed to obtain routine laboratory orders for routine INR (International Normalized Ratio - a test to measure how it takes for blood to clot compared to normal) labs to monitor the use of the anticoagulant, warfarin for 2 of 4 residents (Resident #1 and Resident #4). Resident #1 admitted to the hospital on [DATE] with a critical INR result of greater than 9 (Normal range desired for resident on warfarin is between 2-3) and subdural hematomas with midline shift (occurs when the pressure exerted by the buildup of blood and swelling around the damaged brain tissues is powerful enough to push the entire brain off-center, and is considered a medical emergency). [...]
- 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 clinical record review and staff interview the facility failed to include the use of the anticoagulant medication warfarin for 2 of 2 residents reviewed (Resident #1 and Resident #4). Warfarin requires regular monitoring, assessment, and routine labs due to an increased risk of bleeding. The facility reported a census of 73 residents.
July 11, 2024Complaint inspection · 1 citation
- 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, clinical record review, and staff and resident responsible party interviews, the facility failed to complete appropriate assessments of urinary catheter function in a timely manner, and have needed catheter replacement supplies in the facility, resulting in a residents discomfort and transfer to a local hospital for 1 of 2 residents reviewed for urinary catheter (Resident #3). The facility reported a census of 73 residents. Findings reveal: The 3/7/24 Minimum Data Set (MDS) Assessment tool revealed Resident #3 had diagnoses that included benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptom, cerebrovascular accident (a stroke) with hemiplegia (paralysis on 1 side of the body). [...]
July 27, 2023Standard inspection · 8 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, family and staff interviews, the facility failed to prevent the development of two Stage III (3) pressure ulcers for one of two residents reviewed. (Resident #120). The facility reported a census of 68 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II - A Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote3. The MDS Assessment, dated 4/18/23, listed diagnoses for Resident #9 included: Non-Alzheimer's Dementia, stroke, and anxiety disorder. The MDS assessed the resident independent with transfers, walking in room, and required supervision walking on the unit. The MDS listed the BIMS score as a 3 out of 15, indicating severely impaired cognition. The Care Plan directed staff to monitor the residents' interaction with peers, as she does not like to be touched or have her belongings touched by peers. The Care Plan directed staff to be aware of the need to intervene as needed. An Incident Report, dated 6/8/23, reported during a disagreement Resident #33 pushed Resident #9 down, causing a fracture of her right femur. A Major Injury Determination Form, signed on 6/9/23 by the Medical Director, revealed the Resident #9's right hip fracture qualified as a major injury. [...]
- E
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 clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to perform complete perineal care (washing the resident's genital and anal area) on three of six residents reviewed (Residents #16, #55 and #57) and failed to ensure infection control practices for one of two residents reviewed with indwelling catheters (Resident #59). The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of: non-traumatic brain dysfunction, Non-Alzheimer's Dementia, and muscle weakness. The MDS revealed Resident #57 incontinent of bowel and bladder, required extensive assistance of 2 staff for toilet use and totally dependent on 1 staff for personal hygiene. The MDS identified short term and long term memory loss and severely impaired decision making ability. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure residents remained free from physical resident to resident altercations when one resident (Resident #36) hit two other residents (Resident #17, and #25) in a 24 hour time frame. The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 4/11/23, listed the diagnosis of Resident #36 included: Non-Alzheimer's dementia, depression, and hypertension (high blood pressure). The MDS revealed the resident exhibited difficulty concentrating 12-14 days, short tempered and/or easily annoyed 2-6 days in the 14 days prior to the assessment date. The MDS listed no score for the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The Care Plan revealed the following Focus Areas: 1. [...]
- 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 clinical record review, observations, staff interviews, and review of the facility Gastric Feeding Tube Policy and Procedure, the facility staff failed to follow policy and procedure by not maintaining the residents' head of bed at 45 degrees or above during continuous infusion or stopping the continuous tube feeding infusion if the head of bed was below the 45 degrees for two of two residents reviewed with G-tubes (Resident #51, and #64). The facility reported a census of 68 residents. Findings Include: 1. Resident #64's Minimum Data Set (MDS) completed 6/16/23 listed the total score for the Brief Interview for Mental Status (BIMS) as 7 out of 15, indicating severe impairment. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to provide necessary respiratory care according to the Physician's orders for 1 out of 1 residents reviewed (Resident #2). The facility reported a census of 68 residents.
- 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 clinical record review, staff interviews, and facility policy review, the facility failed to complete and report to the ordering physician the Pharmacist Medication Regimen Review to consider recommendation for a gradual dose reduction of psychotropic medications for two of two residents reviewed, (Resident #27 and #47) . The facility reported a census of 68 residents. Findings Include: 1. Resident #27's Minimum Data Set (MDS) Assessment completed on 4/18/23 recorded the total score for the Brief Interview for Mental Status (BIMS) as 12 out of 15 indicating moderate impaired cognition. Medical diagnoses included major depressive disorder (MDD) and schizoaffective disorder. Antipsychotic and Antidepressant medications were listed along with no Gradual Dose Reduction (GDR) attempted or documented of why not attempted. [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, staff interviews and facility policy review the facility failed to post the current daily staffing for 8 out of 30 days reviewed. The facility reported a census of 68 residents. Findings Include: On 7/18/23 at 11:35 AM, the Nursing Staff on Duty hung on the wall by the front entrance ext to the screening Kiosk dated 7/10/23. On 07/19/23 at 7:50 AM, the Nursing Staff on Duty hung dated 7/18/23. On 7/20/23 at 7:52 AM, the Nursing Staff on Duty still reflected the date 7/18/23. The Nursing Staff on Duty sleeve held one additional posting dated 7/10/23. On 7/20/23 at 7:54 AM, the Administrative Assistant stated the Scheduler is the one who filled out and posts the Nursing on Duty sheets. On 7/20/23 at 9:56 AM, the Scheduler sat in the office by the Nurses Station, held a blue pen as she wrote on the Nursing Staff on Duty sheets. [...]
Fire safety inspections
13 fire safety citations on file: 6 on December 11, 2025, 5 on October 31, 2024, 2 on July 27, 2023.
Every fire safety citation13 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of highly flammable decorations.
K 753 · December 11, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 31, 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 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Have an alternate power supply for its alarm system.
K 344 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · July 27, 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 27, 2023 · Corrected (the home has a date of correction)