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
12D
2E
2F
Potential for minimal harm
0A
0B
0C
December 17, 2025Standard inspection, Complaint inspection · 7 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 facility policy reviews, facility documentation reviews, observations, and interviews, the facility failed to maintain a clean and sanitary kitchen which had the potential to affect 87 of 87 residents.
- 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 facility policy review, observations, interviews, and medical record review, the facility failed to properly store medications and biologicals in 3 medication carts (Cart South-Even, South-Odd, and Skilled) of 3 medication carts observed, and 1 medication room (South) of 2 medication rooms reviewed, and in 1 resident room (Resident #2) of 18 residents reviewed.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on facility policy review, medical record reviews, observation, and interviews, the facility failed to ensure the residents' health information remained private and confidential for 2 residents (Residents #73 and #113) on 1 medication cart (skilled cart) of 5 medication carts observed, which had the potential to allow individuals unauthorized access to the residents' private health information.
- 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 facility policy review, medical record reviews, observations, and interviews, the facility failed to provide a clean and sanitary environment by ensuring cleanliness of personal fans for 2 residents (Residents #41 and #6) of 4 residents reviewed for cleanliness of personal fans.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Residents #3) of 3 residents reviewed for MDS assessments.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to follow physician's orders and the facility policy, for 1 (Resident #24) of 6 residents reviewed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene during meal service for 4 residents (Residents #74, #24, #92, and #19) of 10 residents observed during meal tray distribution on 1 of 4 hallways.
March 30, 2022Standard inspection · 3 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 facility policy review, medical record review, observations, and interviews the facility failed to implement a care plan intervention for 1 resident (Resident #50) of 3 residents reviewed for falls.
- 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 facility policy review, Lippincott procedures review, medical record review, observation, and interview the facility failed to administer enteral feedings (liquid nutrition provided through a tube inserted into the stomach) as ordered for 1 resident (#90) of 3 residents reviewed for enteral feedings.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to ensure infection control practices were followed to prevent the potential spread of infection when 1 of 2 Licensed Practical Nurses (LPN #1) failed to perform hand hygiene during medication administration.
August 14, 2019Standard 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 review of facility policy, facility weekly cleaning schedule, observation, and interview, the facility failed to date and label food items, failed to discard expired foods, failed to maintain clean and sanitary kitchen equipment, failed to separate personal and resident dining items, and failed to secure hair in a hair covering in the 1 of 1 kitchen possibly affecting 117 of 119 residents.
- 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 facility policy review, observation, and interview the facility failed to ensure expired medical supplies were not available for resident use in 2 of 3 medication storage rooms observed.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on facility policy, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (#96, #111) residents of 24 residents reviewed for MDS assessments.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on medical record review and interview, the facility failed to address a wound on the Baseline Care Plan for 1 resident (#259) of 17 residents reviewed for baseline care plans of 24 sampled residents.
- 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 facility policy review, medical record review, observation, and interview the facility failed to develop a comprehensive care plan to address a pressure ulcer for 1 resident (#101) of 5 residents reviewed for pressure ulcers of 24 sampled residents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to address a recommendation from the Registered Dietitian (RD) timely for 1 resident (#78) of 3 residents reviewed for nutrition of 24 sampled residents.
Fire safety inspections
6 fire safety citations on file: 2 on December 17, 2025, 1 on August 7, 2024, 3 on August 14, 2019.
Every fire safety citation6 citations
- 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 · December 17, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 17, 2025 · Corrected (the home has a date of correction)
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · August 7, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 14, 2019 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 14, 2019 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 14, 2019 · Corrected (the home has a date of correction)