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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
3E
0F
Potential for minimal harm
0A
2B
0C
February 11, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to monitor, implement and obtain treatment services from the physician in a timely manner for an identified trauma wound for 1 of 3 sampled residents (Resident #1).
March 13, 2025Standard inspection · 8 citations
- E
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 maintain grooming and personal hygiene for 5 of 28 sampled residents, as evidenced by the failure to timely wash the resident's hair for Resident #53 and #17, failure to provide timely incontinence care for Resident #55 and #79, and failure to provide nail care for Resident #80.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations, interview, policy, and record reviews, the facility failed to provide food in a form to meet the individual needs of residents for 2 of 4 sampled residents (Resident #43, Resident #57) reviewed for pureed texture diets. This had the potential to affect 28 residents who were on pureed texture diets.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, record review, and interview, the facility failed to follow an infection control program to help prevent infections for 5 of 7 sampled residents as evidenced by the failure to ensure physician orders for Enhanced Barrier Precautions (EBP) for Resident #2, #32, and #46, failure to properly maintain the indwelling urinary catheter for Resident #32, and failure to ensure proper hand hygiene and don gloves during eye drop administration for Resident #87. The facility also failed to maintain the laundry area in a manner to prevent the spread of infection.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record reviews, the facility failed to initiate an immediate report in a timely manner in response to an allegation of abuse by 1 of 1 sampled resident reviewed for abuse, Resident #10.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure appropriate care and services for 3 of 28 sampled residents, as evidenced by, the failure to initiate interventions for proper positioning for Resident #95, failure to implement a brace to prevent edema and contractures for Resident #11; and failure to implement interventions in response to low blood sugar levels as per physician orders for Resident #18.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, an interview, and record reviews, the facility failed to monitor the effectiveness of interventions for nutrition for 1 of 18 sampled residents (Resident #26) reviewed for nutrition.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observations, policy review, record reviews, and interviews, the facility failed to have a doctor's order for the administration of enteral feeding, also known as tube feeding, for 1 of 1 sampled resident (Resident #50), reviewed for dependence on enteral feeding to meet their needs for nutrition.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure non-pharmacological interventions to reduce pain during personal care for 1 of 4 sampled residents, Resident #32, who was observed during personal care.
November 16, 2023Standard inspection · 1 citation
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to properly store resident's refrigerated laboratory specimens at the regulatory requirements of 36 degrees F (Fahrenheit) to 46 degrees F.
July 28, 2022Standard inspection · 5 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment in 4 of 67 rooms observed (rooms #104, #111, #209, and the laundry room).
- 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 observation, interviews, and record reviews, the facility failed to ensure implementation of the care pland to provide assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #27).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medications left at bedside for 1 of 6 residents observed during medication pass (Resident #48); and failed to secure medications in a safe manner for 1 of 6 medication carts potentially affecting 19 residents on the 100 Pod.
- B
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to maintain the garbage dumpster in a clean, sanitary condition.
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to accurately complete PASSAR (Preadmission Screening and Record Review) documents for 2 of 2 sampled residents (Resident #72 and Resident #76).
Fire safety inspections
5 fire safety citations on file: 2 on March 13, 2025, 1 on November 16, 2023, 2 on July 28, 2022.
Every fire safety citation5 citations
- D
Provide properly protected cooking facilities.
K 324 · March 13, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 13, 2025 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 16, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 28, 2022 · 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 · July 28, 2022 · Corrected (the home has a date of correction)