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
8D
2E
0F
Potential for minimal harm
0A
0B
0C
June 5, 2026Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 sampled residents, Resident (R)79.
May 16, 2025Standard inspection, Complaint inspection · 4 citations
- 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, interview, record review, and review of facility policy, the facility failed to implement a comprehensive person centered care plan for 2 of 23 sampled residents, (Resident (R)50, and R42). 1. Review of R50's comprehensive person centered care plan revealed the resident was to wear left and right hand and knee splints daily for six days. However, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM , on 05/15/2025 at 9:20 AM and 11:30 AM of R50, revealed two hand splints lying on the resident's bedside table; and observation on 05/16/2025 at 10:18 AM revealed the hand splints were located in R50's closet. Additionally, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM revealed R50 lying on her bed with no knee splints in place and her knees drawn up to her chest. 2. [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion (ROM) for 1 of 23 sampled residents, (Resident (R)50). R50 was care planned with interventions to have left and right wrist and knee splints daily for six days. However, observation revealed two hand splints lying on R50's bedside table or located in the resident's closet. Additionally, observation revealed R50 did not have knee splints on while in bed and the resident's knees were drawn up to her chest.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview, record review, the facility failed to ensure residents received and consumed foods in the appropriate form or the appropriate nutritive content as prescribed for 1 of 23 sampled residents, (Resident (R)42). R42 had a diet order for supervision with all (oral) intake and to have no chips. However, observation on 05/13/2025 at 11:42 AM and 2:48 PM, revealed R42 self-propelling throughout the facility while eating a bag of potato chips unsupervised.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents sampled for wound care out of the total sample of 23 residents (Resident (R)21). Staff providing R21's wound care failed to utilize proper hand washing during the resident's wound care procedure.
April 30, 2021Standard inspection · 5 citations
- E
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 review of the facility's policy, it was determined the facility failed to ensure all residents' drugs and biologicals which were expired were removed from all medication administration areas in order to prevent possible administration to residents.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety as related to the kitchen floor not being clean. Review of facility policy titled, Environment, revision date of 09/2017, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. Observation on 04/27/2021 at 9:51 AM, while on initial tour of the kitchen with the Dietician, it was noted the floors were dirty with dirt, debris and dirty paper towels noted in the floor. Interview with the District Manager of Dietary, on 04/30/2021 at 8:13 AM, revealed that the dietary staff are expected to keep the floor clean. [...]
- 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, record review and facility policy review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of twenty-four (24) sampled residents (Resident #3). The facility failed to ensure Resident #3's Comprehensive Care Plan was revised to include the intervention for bladder cycling related to the Physician's Order received on 04/08/2021. The resident's care plan was not revised to include the intervention until 04/26/2021, fourteen (14) days after the order was received.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interviews, record review and facility policy review, it was determined the facility failed to ensure residents received the necessary care and services to promote healing and prevent infection for one (1) of twenty-four (24) sampled residents, Resident (#33). Observation of a dressing change for Resident #33 revealed the nurse failed to ensure reusable resident care equipment was cleaned and sanitized before and after each use.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, record review, interview and facility policy review, it was determined the facility failed to ensure all residents requiring a therapeutic diet prescribed by the Physician received the diet as ordered for one (1) of twenty-four (24) sampled residents (Resident #56). Resident #56 had a Physician ordered dietary change for a therapeutic diet which the facility failed to implement immediately.
Fire safety inspections
6 fire safety citations on file: 1 on June 5, 2026, 1 on May 16, 2025, 4 on April 30, 2021.
Every fire safety citation6 citations
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 5, 2026 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · May 16, 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 30, 2021 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 30, 2021 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 30, 2021 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 30, 2021 · Corrected (the home has a date of correction)