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
13D
2E
1F
Potential for minimal harm
0A
0B
0C
January 9, 2026Standard inspection, Complaint inspection · 5 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers as scheduled for 1 of 4 residents reviewed for Activities of Daily Living (ADLs). (Resident G)
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review, the facility failed to timely ensure vision services were provided for 2 of 2 residents reviewed for vision and hearing services. (Residents B and H)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was seen by urology for 1 of 2 residents reviewed for catheter care. (Resident 111)
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, observation, and record review, the facility failed to accurately transcribe admission order for Resident D, have pain medication available as ordered for Resident D, and failed to address pain for Resident H for 2 of 2 residents reviewed for pain control.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview and record review the facility failed to provide a substitute at lunch as requested by the resident for 1 of 1 residents reviewed for nutrition (Resident 70). Review of the clinical record of Resident 70 on 1/07/2026 11:55 a.m., indicated the resident's diagnoses included, but were not limited to, vascular dementia, cerebral vascular disease, major depression disorder, adult failure to thrive and hypertension. The food preference assessment for Resident 70, dated 11/21/25, indicated the resident typically consumed salads. The resident requested salads for breakfast, lunch and dinner. The resident also liked fruit, chocolate milk, eggs, cheese, potatoes, fish, grilled cheese and peanut butter and jelly sandwiches. [...]
December 10, 2024Standard inspection · 3 citations
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on interview and record review, the facility failed to provide weekend activities, as preferred, for 2 of 4 residents reviewed for activities (Residents 13 and 71). This had the potential to affect 19 of 19 residents on the Reflections 1 Unit of the facility.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to include a resident and a resident's representative in their care plan conferences for 2 of 5 residents reviewed for care planning. (Residents 13 and 104)
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Resident 36's indwelling urinary catheter remained free of contact with the floor while in bed for 1 of 2 residents reviewed for indwelling urinary catheters.
September 5, 2024Complaint inspection · 1 citation
- 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 misappropriation of residents' medication did not occur for 1 of 3 residents reviewed for medication administration. (Resident C)
June 26, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to provide medications as ordered by the physician for 1 of 3 residents reviewed for medication administration. (Resident C)
September 13, 2023Standard inspection · 6 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 observation and interview, the facility failed to ensure that food was dated, out of date food was removed, and a storage scoop was not stored inside of a container with food. This had the affect 112 of 115 residents who resided in the facility.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing activity program on the memory care unit for 7 of 9 resident's reviewed for activities (Resident 5, Resident 26, Resident 32, Resident 37, Resident 55, Resident 71 and Resident 77).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview and record review the facility failed to have a care plan meeting and failed to develop a care plan to self administer medications for 2 of 6 residents reviewed for care planning (Resident 10 and Resident 64).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking materials were kept in a secure location, per facility policy, for 1 of 3 residents reviewed for smoking. (Resident 86)
- 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 failed to follow-up with pharmacy recommendations and give a rationale for declining a gradual dose reduction (GDR) for 2 of 5 residents reviewed for unnecessary medications. (Resident 13 and Resident 57)
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program related to mitigation efforts to minimize the potential for ants for 1 of 2 residents reviewed for environment. (Resident 30)
Fire safety inspections
14 fire safety citations on file: 6 on January 9, 2026, 2 on December 10, 2024, 6 on September 13, 2023.
Every fire safety citation14 citations
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 9, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 9, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 9, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 10, 2024 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · December 10, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 13, 2023 · Corrected (the home has a date of correction)
- E
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 · September 13, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · September 13, 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 · September 13, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 13, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 13, 2023 · Corrected (the home has a date of correction)