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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
5E
0F
Potential for minimal harm
0A
0B
0C
July 1, 2026Complaint inspection · 1 citation
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to routinely document physician-ordered daily weights for 1 of 3 residents reviewed for following physician care orders. (Resident B)
March 27, 2026Standard inspection, Complaint inspection · 6 citations
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to offer and provide education on the 2025-2026 Covid-19 vaccination and maintain documentation of such for 5 of 5 residents reviewed. (Residents 3, 7, 9, 10, and 12)
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents maintained dignity by answering call lights in a timely manner, resulting in incontinence leading to residents feeling uncomfortable and embarrassed for 2 of 4 residents reviewed for resident rights. (Resident F and Resident E)
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from misappropriation of their narcotic medication for 1 of 1 resident reviewed for misappropriation. (Resident B)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident with feeding who had weight loss for 1 of 4 residents reviewed for nutrition. (Resident 8)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store respiratory supplies correctly at the bedside for 1 of 1 resident reviewed for respiratory care. (Resident 21)
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule an oral surgeon appointment, as referred, and follow-up on a recommendation for a new toothbrush and water flosser for 1 of 1 resident reviewed for dental status and services. (Resident 12)
February 27, 2025Standard inspection, Complaint inspection · 6 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatments were completed and documented on night shift and a resident had a fall intervention in place for 5 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for falls. (Residents C, G, 7, 9, 24, and 36)
- E
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review, the facility failed to monitor and document target behaviors for 5 of 5 residents reviewed for unnecessary medications. (Residents C, G, 7, 9, and 36)
- E
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 interview and record review, the facility failed to monitor for side effects of psychotropic medications, as ordered, for 5 of 5 residents reviewed for unnecessary medications. (Residents C, G, 7, 9, and 36)
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wrote2. An interview was conducted with Resident 14 on 2/25/25 at 11:25 a.m. They indicated the facility food was not good. A test tray of the facility lunch meal was provided by the Clinical Support on 2/25/25 at 12:10 p.m. It included a frittata, diced potatoes, broccoli, and a roll. Three out of four of the foods were yellow in color and did not appear appetizing. The frittata had a bland taste with an unappealing texture. The diced potatoes were bland tasting and lacked any flavor. The broccoli was overcooked, mushy, and bland tasting. The roll was soggy on the bottom from the broccoli juices. An interview was conducted with Resident 14 on 2/25/25 at 2:02 p.m. He indicated the above lunch meal was not good at all. He didn't eat the diced potatoes, because he didn't like them, and didn't eat the roll, because he didn't want it. 3. [...]
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper eating utensils were provided to 1 of 1 resident reviewed for assistive devices. (Resident 29)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device for 1 of 2 residents reviewed for catheters (Resident C).
December 12, 2023Standard inspection · 3 citations
- D
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 interview and observations, the facility failed to promote a clean environment for Resident 6 by having a thick layer of dusk on her over bed tables, including her personal items and plants, as we well as a thin layer of dust on her window ledge for 1 of 3 resident reviewed for environmental concerns.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review the facility failed to provide routine optometry services for a resident experiencing blurred vision for 1 of 1 resident reviewed for vision (Resident 30).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and record review the facility failed to provide routine dental services for a resident with missing teeth and a chipped tooth for 1 of 2 residents reviewed for dental services (Resident 30).
Fire safety inspections
12 fire safety citations on file: 3 on March 27, 2026, 7 on February 27, 2025, 2 on December 12, 2023.
Every fire safety citation12 citations
- E
Meet other general requirements that are deficient.
K 300 · March 27, 2026 · 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 · March 27, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 27, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 27, 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 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 27, 2025 · Waiver
- E
Meet other general requirements that are deficient.
K 300 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 27, 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 · December 12, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 12, 2023 · Corrected (the home has a date of correction)