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 13 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
1E
0F
Potential for minimal harm
0A
0B
0C
November 19, 2025Standard inspection · 3 citations
- E
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 review, observation, and interview, the facility failed to maintain a clean and sanitary environment when food debris was found on top of and inside the deep fryer, oil was observed dripping from the fryer onto the floor, a black, dried liquid substance was observed on the floor behind and around the stove, oven, deep fryer, ice machine, along the base boards and in the corners of the kitchen and when carbon build up and food debris was observed on the stovetop. The facility's census was 112 and 111 residents received meal trays from the kitchen.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, policy review, medical record review, and interview, the facility failed to ensure assessments were signed to reflect timely submission and failed to complete quarterly assessments timely, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 3 of 23 (Resident #5, #92, and #148) sampled residents reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guideline review, policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of communicable diseases when 3 of 3 staff (Certified Nursing Assistant (CNA) A, CNA B, and CNA C) failed to don personal protective equipment (PPE) and properly perform urinary catheter care for 2 of 2 (Resident #135 and #158) sampled residents reviewed for enhanced barrier precautions and catheter care.
August 23, 2024Standard inspection, Complaint inspection · 9 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure call lights were within reach for 1 of 118 (Resident #82) sampled residents reviewed for access to call lights.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, Facility Reported Investigation (FRI) review, and interview, the facility failed to report allegations of abuse within 2 hours for 2 of 3 (Residents #170 and #270) sampled residents reviewed for abuse.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on facility policy review, Resident Assessment Instrument (RAI) Version 3.0 Manual review, medical record review, and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 4 residents (Resident #273) reviewed.
- 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 facility policy review, medical record review, document review, and interview the facility failed to revise care plans for 2 of 5 (Residents #170 and #270) sampled residents reviewed for resident-to-resident physical altercations, 1 of 6 (Resident #175) sampled residents reviewed for fall interventions, 1 of 3 (Resident #111) sampled residents with urinary catheters, 1 of 5 (Resident #18) sampled residents reviewed for changes to antipsychotic medication, and 1 of 4 (Resident #273) sampled residents reviewed for hospice services.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on facility policy review, facility documentation, and interview, the facility failed to provide incontinence care for 6 of 31 (Residents #6, #40, #55, #99, #103, and #108) sampled residents reviewed for incontinence care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to follow Medical Doctor's (MD) orders for 1 of 9 (Resident #275) sampled residents reviewed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on facility policy review, medical record review, facility documentation, and interview, the facility failed to implement an effective pain management regimen for 1 of 6 (Resident #111) sampled residents reviewed for pain management.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility policy review, medical record review, facility document review, and interview the facility failed to provide pharmaceutical services policies and procedures that ensured the dispensing and disposition (possession or control of medication) of physician ordered medications to meet the needs of each resident in 1 of 1 (Resident #275) sampled resident reviewed for taking medications brought in from home by a family member.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on facility policy, observation, and interview the facility failed to maintain a resident call system to allow a resident or resident representative to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 of 31 (Resident #105) sampled residents reviewed.
September 11, 2019Standard inspection · 1 citation
- 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 facility policy review, medical record review and interview, the facility failed to provide a duration for the use of a PRN (as needed) psychotropic (chemical substance that alters perception, mood, consciousness, cognition or behavior) medication for 1 (#14) of 16 residents reviewed for unnecessary medications.
Fire safety inspections
14 fire safety citations on file: 3 on November 19, 2025, 10 on August 23, 2024, 1 on September 11, 2019.
Every fire safety citation14 citations
- D
Have restrictions on the use of portable space heaters.
K 781 · November 19, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 19, 2025 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · November 19, 2025 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Create arrangements with other facilities to receive patients.
E 25 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Establish staff and initial training requirements.
E 37 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 23, 2024 · 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 · August 23, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · August 23, 2024 · Corrected (the home has a date of correction)
- D
Ensure gas cylinders are properly stored.
K 906 · September 11, 2019 · Corrected (the home has a date of correction)