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
0G
0H
0I
Potential for more than minimal harm
7D
1E
2F
Potential for minimal harm
0A
0B
0C
July 9, 2026Standard inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Fingernails/Toenails, Care of, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of five sampled residents (R) (R110 and R22). This deficient practice had the potential to place R110 and R22 at risk of infection and cause the residents to feel self-conscious about their appearance.
April 17, 2025Standard inspection, Complaint inspection · 7 citations
- F
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 observations, staff interview, and record review, the facility failed to ensure that the preplanned menu portion serving sizes and standardized recipes were followed. Failure to meet these requirements altered the intended calorie and nutritional content of the meal offered and could place residents at risk for weight loss and health complications associated with malnutrition. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen.
- 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, staff interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions; as evidenced by failure to ensure food preparation equipment was stored under sanitary conditions; and ensure food storage areas were kept clean and sanitary. In addition, the facility failed to ensure foods were cooked to the appropriate temperature before placing them in a warmer (a low temperature oven intended to hold hot food), and failure to ensure ready to eat foods were handled in a manner that prevented contamination. The deficient practice increased the risk for all residents residing in the facility who receive a diet from the kitchen could experience a food borne illness.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, interviews, and policy reviews, the facility failed to ensure five of 10 residents and their representatives (Resident (R) 8, R7, R23, R45, and R74) reviewed for facility initiated emergent hospital transfer from a total sample of 31 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred, and/or how to appeal a transfer, if desired.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff interviews, and record review, the facility failed to provide staff assistance with activities of daily living for one of four residents (Resident (R) 244) reviewed for activities of daily living out of a total sample of 24 residents. This failure had the potential to lead to a decline in activities of daily living.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on record reviews, and staff interviews, the facility failed to ensure physician orders were followed related to laboratory monitoring for one of one (Resident (R)45) residents reviewed for laboratory services. Specifically, the facility failed to ensure that R45's HbA1c (blood test measuring average blood sugar levels over the past two to three months) labs were drawn in October 2024 and January 2025.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and record review, the facility failed to maintain a complete and accurate medical record for one of 31 sampled residents (Resident (R) 8). Specifically, the facility failed to include the physician order for metoprolol tartrate 25 milligrams (mg) into the electronic medical record (EMR) following a readmission after hospital discharge. This failure had the potential to cause a medication error that could be harmful to the resident.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure infection control was maintained for five of 31 sampled residents (Resident (R) 17, R53, R59, R61, and R84). Specifically, the facility failed to ensure that hand hygiene was completed during medication administration, meal service, and housekeeping tasks. Additionally, a personal drink was on top of the medication cart during medication pass which increased the risk for cross contamination and infections.
December 15, 2022Standard inspection · 2 citations
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Discharging the Resident the facility failed to complete a recapitulation of stay and discharge summary for one resident (R) R#92 of 11residents discharged from the facility in the last three (3) months. The deficient practice had the potential to affect the continuance of care for R#92 after being discharged from the facility.
- 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 observations, record review, staff interviews and review of the facility policy titled, Medication Monitoring and Management, the facility failed to ensure that a psychotropic medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one (1) resident (R) R#33 of five (5) residents reviewed for unnecessary medications. Specifically, the facility failed to ensure that there was a stop order date for Klonopin prescribed for R#33.
Fire safety inspections
13 fire safety citations on file: 3 on July 9, 2026, 7 on April 17, 2025, 3 on December 15, 2022.
Every fire safety citation13 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 9, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 9, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · July 9, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 17, 2025 · Corrected (the home has a date of correction)
- D
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 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · December 15, 2022 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · December 15, 2022 · Corrected (the home has a date of correction)