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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
1E
0F
Potential for minimal harm
0A
0B
0C
March 25, 2026Standard inspection · 0 citations · risk-based survey (a shorter visit CMS gives only to higher performing homes)
September 24, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 2 of 4 sampled residents (R1 and R2). R1 made an allegation of abuse against R2 to her daughter that was overheard by an RN (Registered Nurse). The RN did not report the allegation of abuse. CMS's indicates abuse is to be reported within 2 hours, as identified, in part, by 483.12(c)(1) as: [...]
- 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 record review and staff interview the facility did not develop and implement a Comprehensive Resident Centered Care Plan for 1 of 4 residents reviewed (R 2). R2's medical record indicated R1 had occasional sexual inappropriate behaviors. R2's comprehensive care plan does not include a care plan for sexual inappropriate behaviors. Evidenced by:The facility's Multidisciplinary Plan of Care Policy, undated, includes in part the following: D. The comprehensive plan of care is maintained in the electronic medical record (EMR) and is updated to reflect the resident's current status and goals. It will be reviewed at minimum quarterly and per resident need. R2 was admitted to the facility 9/12/24. R2's diagnosis include dementia, history of stroke, osteoarthritis and diabetes. [...]
September 3, 2025Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility did not promptly notify and consult with a physician when a resident experienced a potential change in condition for 1 of 3 resident's (R1) reviewed for physician notification. R1 experienced consistently low blood pressure while taking Metoprolol (a beta blocker that lowers blood pressure) and the facility did not notify R1's physician. The Mayo Clinic, Cleveland Clinic, John Hopkins, University of Wisconsin Hospital, [NAME] Health, and the American Heart Association (AHA) define hypotension (low blood pressure) as being below 90/60 mm Hg (milliliters of mercury). According to the Mayo Clinic, Complications of C. difficile infection include: loss of fluids, called dehydration. Severe diarrhea can lead to a serious loss of fluids and minerals called electrolytes. This makes it hard for the body to work as it should. [...]
December 5, 2024Standard inspection · 3 citations
- D
Provide appropriate foot care.
Inspectors wroteBased on interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 1 of 1 resident (R10) reviewed for diabetic foot checks. R10 has no documentation of diabetic foot checks. This is evidenced by: Per ADA (American Diabetes Association), dated 2017, foot checks/screens should be conducted daily with a comprehensive exam conducted annually. Per AMDA (American Medical Director Association), dated 12/9/14, these foot checks/screens are vitally important for treatment of foot problems in patients with diabetes. Common foot problems in diabetic patients are broken down into three categories: at-risk foot, current mild foot/ankle or heel infection or ulcer, and limb-threatening foot/ankle/heel ulcer. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for nutritional status (R29). R29 experienced a significant weight loss, and the facility did not assess and notify the physician.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 2 supplemental residents (R11 and R186) reviewed for antibiotic stewardship. R11 was treated with an antibiotic for an UTI (urinary tract infection) without meeting criteria. R186 was treated with an antibiotic for an UTI and did not meet criteria. Evidenced by: The facility policy, entitled Antimicrobial Stewardship Program, 7/22/24, states, in part: . POLICY: A. (Facility Name) has established and will maintain an antimicrobial stewardship program (AMS). AMS programs promote appropriate antibiotic prescribing practices and play a critical role in reducing antibiotic resistance . C. The Antibiotic Stewardship Team will be responsible for, at a minimum: . b. [...]
October 5, 2023Standard inspection · 3 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 interview and record review the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 5 sampled residents (R14) and 3 of 3 supplemental residents (R10, R15, R18) receiving an anticoagulant medication. The facility did not develop a Care Plan for precautions or monitoring related to use of anticoagulation medication for R10, R15, R14 and R18. Evidenced by: (It is important to note the facility did not have a policy related to the use of anticoagulants.) The facility policy, entitled Multidisciplinary Plan of Care, undated, includes, in part: The multidisciplinary plan of care is developed as soon as possible after the resident is admitted . A basic care plan is developed within 48 hours by the Interdisciplinary Team. [...]
- 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 interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 2 of 5 residents reviewed for unnecessary medications (R33 & R21). R33 did not have a monthly medication review conducted by a pharmacist. R21 did not have a monthly medication review conducted by a pharmacist.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and pneumococcal immunization for 1 of 5 residents (R25) reviewed for immunizations. R25 did not receive the pneumococcal vaccine. This is evidenced by: The facility's policy titled Pneumovax Vaccine, no date, states in part: A. On admission to LTC (Long Term Care) and with a MD (Medical Doctor) order, pneumovax vaccine will be encouraged for all resident who have not previously received this vaccine .2. Each resident or resident's legal representative receives education regarding the benefits and potential side effects of immunization .5. [...]
Fire safety inspections
13 fire safety citations on file: 7 on March 25, 2026, 6 on December 5, 2024.
Every fire safety citation13 citations
- F
Address subsistence needs for staff and patients.
E 15 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · March 25, 2026 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 5, 2024 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 5, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 5, 2024 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · December 5, 2024 · Corrected (the home has a date of correction)