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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
6D
2E
0F
Potential for minimal harm
0A
1B
0C
July 8, 2026Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, clinical record review, interviews, and policy review the facility failed to monitor and maintain documentation of a resident's bruises for 1 of 1 residents reviewed (Resident #1). Additionally, the facility failed to obtain x-ray results for a resident with hip pain after falling for 11 days for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 60 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review, facility records, interviews, and policy review, the facility failed to provide adequate supervision for 2 of 3 residents reviewed for falls (Resident #1 and Resident #3). Resident #1 fell after a Certified Nurses' Aide (CNA) transferred them to the edge of the bed and then moved a wheelchair to the bathroom. Additionally, Resident #3 required assistance from a CNA, but the staff left them alone in the bathroom while the CNA assisted another resident. In addition, the facility failed to use foot pedals while pushing Resident #3 who needed assistance in their wheelchair. The facility reported a census of 60 residents.
November 17, 2025Standard inspection · 1 citation
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on Electronic Health Record (EHR) review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews the facility failed to accurately code 1 of 1 resident (Resident #9) Minimum Data Set (MDS) assessment for hospice services during the look back period. The facility reported a census of 66.
October 9, 2024Standard inspection · 2 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review, document review and staff interview, the facility failed to complete a new level 1 Preadmission Screening and Resident Review (PASRR) screening for 1 of 1 resident's sampled (Resident #19). The facility identified a census of 66 residents.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview the facility failed to accurately code 1 of 16 residents Minimum Data Set (MDS) accurately (Resident #59). The facility reported a census of 66 residents.
July 16, 2024Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record review, observations, staff, resident, and family interviews the facility failed to provide adequate supervision for 1 of 3 residents reviewed with falls (Resident #1). On 1/25/24, Resident #1 fell while receiving assistance from a Certified Nurse Aide (CNA). As the CNA assisted Resident #1 she failed to apply a gait belt. The fall resulted in a hip fracture to Resident #1's right hip that required surgical repair. The facility reported a census of 63.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on clinical record review, observations, staff, and resident interviews the facility failed to ensure their call light system properly functioned for 2 of 4 resident neighborhoods observed (Community and Excellence) affecting 3 of 63 resident rooms (room [ROOM NUMBER], 4001 and 4010). The facility reported a census of 63.
August 10, 2023Standard inspection · 3 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to follow the menu and substitute menu item that wasn't available in the Community household. The facility reported a census of 68 residents.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wrote2. On 8/9/23 at 8:10 AM observed a half gallon of milk on the counter of the first floor, Progressive household kitchen, milk observed to be used for filling resident glasses during the breakfast service. The milk was used and placed back on the counter throughout the breakfast meal. On 8/9/23 at 8:37 AM observed Dietary Management Staff A and Dietary Management Staff B entered the kitchen during meal preparation, conversed message to staff in the kitchen. The staff entered the kitchen during meal preparation and serving, they did not wear hairnets. On 8/9/23 at 8:50 AM observed Staff C put the half gallon of milk into the refrigerator, requested the temperature of the milk. Staff C poured a glass of milk for temperature check and tempted the milk in the glass. The temperature of the milk was fifty-seven (57) degrees. [...]
- 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 policy review, the facility failed to ensure residents remained free from abuse for 1 of 1 residents reviewed for abuse (Resident #35). The facility reported a census of 68 residents.
Fire safety inspections
17 fire safety citations on file: 3 on November 17, 2025, 3 on October 9, 2024, 11 on August 10, 2023.
Every fire safety citation17 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 17, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 17, 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 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 9, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 10, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 10, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 10, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 10, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 10, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 10, 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 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 10, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · August 10, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 10, 2023 · Corrected (the home has a date of correction)