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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
8E
1F
Potential for minimal harm
0A
0B
0C
February 19, 2026Complaint inspection · 1 citation
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to keep confidential all information in a resident's medical record for three of eight residents reviewed (Residents 3, 5, and 8).
September 24, 2025Complaint inspection · 1 citation
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, and resident and staff interview, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures on one of three open nursing units (Evergreen, Residents 2 and 3).
August 22, 2025Standard inspection, Complaint inspection · 11 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 staff interview, it was determined that the facility failed to store and serve food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of three open nursing units (Memory Care and Evergreen).
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on a review of select facility policies and procedures, the facility's grievance documentation, observation, and resident and staff interview, it was determined that the facility failed to implement effective corrective action in response to a resident's grievance related to staff call bell response for seven of seven residents reviewed for call bell response concerns (Residents 20, 108, 111, 48, 93, 107, and 3).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for two of two residents reviewed for antibiotic use (Residents 107 and 111), for three of three residents reviewed for transmission based precautions (Residents 3, 48, and 51), and for the facility's water management program.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure resident dignity during dining on one of three open nursing units (Memory Care, Residents 18 and 36).
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to a resident prior to a facility-initiated room change for one of one resident reviewed for concerns related to resident choice (Resident 107).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide assistance with activities of daily living (ADL) for dependent residents for two of two residents reviewed for ADL concerns (Residents 107 and 90).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent resident elopement for one of two residents reviewed for elopement concerns (Resident 15).
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on review of facility documentation, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with indwelling catheters and medication administration for three of four employees reviewed (Employees 4, 11, and 14).
- D
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on staff interviews it was determined that the facility failed to have sufficient competent dietary staff to perform essential kitchen duties (Employee 2).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for three of 20 residents reviewed (Residents 4, 82, and 105).
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of select facility policies, clinical record review, and staff interview it was determined that the facility failed to administer a pneumococcal vaccine to a resident who consented to and was eligible to receive it for one of five residents selected for vaccination review (Resident 53).
September 27, 2024Standard inspection · 8 citations
- E
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 observations, and staff and family interview, it was determined that the facility failed to provide adequate maintenance services to maintain an orderly environment in a main hallway of the facility (Resident 29).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding cardiac pacemakers and central venous catheters for three of 19 residents reviewed (Residents 27, 61, and 82).
- E
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 staff interview, it was determined that the facility failed to store food items and maintain equipment in a sanitary manner in the facility's main kitchen.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives for one of five residents reviewed (Resident 66).
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide care or services to maintain a resident's ambulation status for one of two residents reviewed for ambulation concerns (Resident 17).
- 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 observations, clinical record review, and staff interview, it was determined that the facility failed to appropriately use a positional device related to contractures for one of two residents reviewed (Resident 80).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a complete medical record was accessible to the survey team timely for one of six residents reviewed (Residents 10).
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to offer the COVID-19 vaccine to one of five residents reviewed for immunizations (Resident 59).
October 27, 2023Standard inspection · 9 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for one of 19 residents reviewed (Resident 70).
- E
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 staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner in the facility's main kitchen and on one of six nursing units (Evergreen Nursing Unit).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on review of select facility policy and procedures, observation, and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 19 residents reviewed (Resident 12).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving the potential for abuse for one of 19 residents reviewed (Resident 60).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 19 residents reviewed (Residents 87).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, clinical record review, and resident, responsible party, and staff interview, it was determined that the facility failed to provide a dependent resident assistance with nail care for one of one resident reviewed for activities of daily living (Resident 11).
- 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 clinical record review and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion for one of four residents reviewed (Residents 19).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls and/or injuries for one of seven residents reviewed (Resident 60).
- 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 clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding bladder incontinence for one of two residents reviewed (Resident 4).
Fire safety inspections
13 fire safety citations on file: 2 on August 22, 2025, 7 on September 27, 2024, 4 on October 27, 2023.
Every fire safety citation13 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 · August 22, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 22, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · September 27, 2024 · 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 27, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 27, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 27, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 27, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 27, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 27, 2024 · 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 · October 27, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 27, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 27, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 27, 2023 · Corrected (the home has a date of correction)