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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
13D
10E
2F
Potential for minimal harm
0A
0B
0C
December 18, 2025Standard inspection · 8 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, review of select facility policies and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food and failed to record and maintain food temperature logs to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument (RAI) and staff and resident interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 15 sampled (Residents 16 and 34).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication for two of 15 sampled residents (Resident 12 and 36).
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on a review of the facility's plan of correction from the survey ending December 18, 2025, the documented outcomes of the facility's Quality Assurance and Performance Improvement (QAPI) committee, clinical record reviews, and staff interviews, it was determined the facility failed to ensure its quality assurance program effectively identified and addressed recurring deficient practices related to nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders (Residents 1, 2, and 3).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, a review of select facility policy, and interviews with staff, it was determined that the facility failed to ensure personnel must handle, store, process, and transport linens in order to prevent the spread of infection in one out of one laundry room.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on a review of clinical records, select facility policies, the Center for Disease Control and Prevention (CDC) Adult Vaccine Schedules, and staff interview, it was determined the facility failed to ensure residents were offered and/or provided recommended influenza and pneumococcal immunizations for two of five residents reviewed for immunizations (Residents 6 and 16).
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on a review of clinical records and staff and resident interviews, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and arrange for treatment by a professional specializing in the provision of vision assistive devices as needed for one out of 15 residents sampled (Resident 16).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on a review of select facility policies, clinical records, and staff interviews, it was determined the facility failed to assess, evaluate, and monitor the nutritional parameters of a resident with significant weight loss for one of 15 residents reviewed (Resident 2).
February 28, 2025Standard inspection, Complaint inspection · 9 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents as expressed by three out of four residents interviewed during a resident group interview. (Residents 4, 6, and 8).
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of clinical records, select facility policy, and staff interview it was determined the facility failed to monitor the nutritional parameters of two residents (Resident 36 and Resident 20) with an identified significant weight loss and failed to implement a planned nutrition intervention in response to weight loss for one resident (Resident 20) out of 13 residents sampled.
- E
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 a review of clinical records and staff interview, it was determined the physician failed to act upon pharmacist identified irregularities in the medication regimen of three of 13 residents sampled (Resident 11, 24, and 4).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on a review of clinical records, select facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to ensure that residents are free from physical restraints that are not required to treat a resident's medical symptoms for one resident out of three closed records reviewed (Resident 196).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 13 sampled. (Residents 4).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs, and failed to follow physician orders for management of a PICC line for one of 13 residents sampled (Resident 94).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on a review of select facility policy, observation, and staff interview, it was determined the facility failed to maintain respiratory equipment in a manner to promote optimal functioning for one resident out of 13 sampled residents. (Resident 24).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate accounting of controlled drugs when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 43).
- 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 clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the increase of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use. (Resident 2).
March 28, 2024Standard inspection · 8 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and interviews with staff and a resident's family, it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain the physical health of one resident out of 14 residents sampled (Resident 33), resulting in an sprained ankle, which caused the resident pain and a decline in abilities to perform activities of daily living.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interview and a review of employee time sheets and qualifications, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and resident pantry.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide reasonable accommodations to facilitate a resident's participation in activities for one of the 14 residents sampled (Resident 41).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on a review of the facility's abuse policy and employee personnel files and staff interview, it was determined that the facility failed to implement their established abuse prohibition procedures for fully screening and training one employee out of five reviewed to ensure that they were eligible for employment in a long-term care nursing facility (Employee 1).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interviews, it was determined that the facility failed to timely report an instance of resident neglect to the State Survey Agency for one out of the 14 residents reviewed (Resident 33).
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on review of clinical records and staff interviews, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 14 sampled (Resident 8)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on a review of clinical records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records consistent with professional standards of practice by failing to timely and accurately document the facility's response to a change in a resident's condition for one resident out of 14 sampled.
December 27, 2023Complaint inspection · 1 citation
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of clinical records, select facility policy and grievances lodged with the facility, and resident and staff interviews, it was determined that the facility failed to provide care in an environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by five residents out of nine interviewed (Residents 2, 7, 1, 6, and 8 ).
Fire safety inspections
7 fire safety citations on file: 3 on December 18, 2025, 2 on February 28, 2025, 2 on March 28, 2024.
Every fire safety citation7 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 18, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 18, 2025 · Corrected (the home has a date of correction)
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 18, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 28, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 932 · February 28, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 28, 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 · March 28, 2024 · Corrected (the home has a date of correction)