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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
23D
8E
1F
Potential for minimal harm
0A
0B
0C
December 3, 2025Complaint inspection · 2 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteA past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 11/07/25 related to the facility's failure to provide supervision to prevent elopement. Based on observation, record review, and interview, the facility failed to ensure a resident requiring increased visual checks was not neglected for 1 (#1) of 3 sampled residents reviewed for neglect. LPN #1 identified 119 residents resided in the facility. The DON identified 21 residents at risk for elopement.
- J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteA past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 11/07/25 related to the facility's failure to provide implement interventions for a resident with a known history of elopement. Based on record review and interview, the facility failed to implement care plan interventions for 1 (#1) of 3 sampled residents reviewed for care plan interventions with a known history of elopement risk. LPN #1 identified 119 residents resided in the facility. The DON identified 21 residents at risk for elopement.
November 26, 2025Complaint inspection · 1 citation
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from abuse for 1 (#2) of 3 sampled residents reviewed for abuse. The DON identified 115 residents resided in the facility.
September 18, 2025Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThe Immediate Jeopardy (IJ) has been removed based on a determination resulting from an Informal Dispute Resolution (IDR). On 09/18/25 at 1:23 p.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect residents from physical abuse. Resident #2 was involved in an altercation with Resident #1 resulting in a fist fight and Resident #1 falling to the ground. Resident #2 continued to sit on and hit Resident #1. Resident #1 lost their balance during the altercation and fell to the floor resulting in a fracture of their left femur. Based on record review and interview, the facility failed to ensure a resident was protected from physical abuse inflicted by another resident for 1 (#1) of 4 sampled residents reviewed for abuse. The administrator identified 117 residents resided in the facility.
March 17, 2025Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's personal funds were not misappropriated for 1 (#4) of 4 sampled residents reviewed for abuse. The assistant director of nursing identified 112 residents resided in the facility.
January 21, 2025Standard inspection, Complaint inspection · 13 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteOn 01/17/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #18 was free from abuse by not implementing company policy and procedures. This resulted in Resident #18 experiencing psychosocial harm. A nursing note, dated 12/25/24 at 9:39 a.m., read in part, [Resident #18] was observed walking down 400 hallway. [Resident #54] got mad and started ranting saying that,I will stub them because they didn't like that particular resident. The note also read, [Resident #54] pulled out a rail road track nail with the gestures of attacking [Resident #18]. The note also read, This Nurse yelled for help along side the Nurse aide who was close and witnessed they rushed to intercept and prevent any possible attack to the [Resident #18] who was asked to go back in their room. [...]
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. wound care was provided as ordered for two (#12 and #57); b. care was coordinated for a non pressure wound for one (#12); c. an order was obtained prior to providing wound care to a resident's wound for one (#12); d. the nurse was notified when the dressing of a wound became dislodged for one (#12); e. staff documented changes in the resident's skin before leaving for the day for one (#12); and f. treatment orders were obtained at the time a new wound was identified for one (#12) of four sampled residents reviewed for non pressure skin conditions. This resulted in actual harm when Resident #12's left gluteal fold wound increased in size after the facility failed to provide treatment as ordered. The administrator identified 114 residents resided in the facility. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record and interview, the facility failed to thoroughly investigate an allegation of abuse for two (#18 and #54) of three sampled residents reviewed for abuse and neglect. The administrator reported the census was 114.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were completed timely for two (#67 and #98) of 28 sampled residents reviewed for resident assessments. The administrator identified 114 residents resided in the facility.
- 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 interview, the facility failed to ensure the low temperature dishwasher had the appropriate amount of chemicals to sanitize dishes for three of four observations of dishwasher chemical sanitization level checks. ADON #1 identified 112 residents ate meals from the kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. wound care was provided in a manner to prevent cross contamination for two (#12 and #57) of three sampled residents observed for wound care; b. a urinary catheter was stored in a manner to prevent cross contamination for one (#12) of one sampled resident observed with a urinary catheter; and c. infection control logs were completed for five (#22, 25, 54, 81, and #86) of five sampled residents reviewed for staph infections. The administrator identified 114 residents resided in the facility. The DON identified 10 residents with non pressure wounds, two residents with staph infections, and two residents with urinary catheters resided in the facility.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the physician was notified when a resident experienced a change in their skin condition that required medical intervention for one (#12) of four sampled residents reviewed for non pressure skin conditions. The administrator identified 114 residents resided in the facility. The DON identified 10 residents with non pressure wounds resided in the facility.
- 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 provide a safe, clean, and comfortable shower room in three of the four shower rooms observed. ADON #1 identified the facility had seven shower rooms.
- 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, record review, and interview, the facility failed to ensure a resident care plan was revised for one (#57) of one sampled resident observed self-administering a medication. The administrator identifed no residents with orders to self-administer medications resided in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure wound care was provided as ordered for one (#17) of two sampled residents reviewed for pressure ulcers. ADON #2 identified three residents with pressure ulcers resided in the the facility.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure qualified staff were present during medication administration for one (#57) of one sampled resident observed self-administering a medication. The administrator identifed no residents with orders to self-administer medications resided in the facility.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medical records were accurately documented for one (#57) of 26 sampled residents reviewed for medical record accuracy. The administrator identified 114 residents resided in the facility. The DON identified 10 residents with non pressure wounds resided in the facility.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review and interview, the facility failed to ensure the facility antibiotic stewardship program was implemented for one (#25) of five sampled residents reviewed for staph infections. The DON identified two residents with a current staph infection resided in the facility.
December 5, 2024Complaint inspection · 2 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to implement QAPI for incident reporting of one (#1) of five sampled residents reviewed for abuse and neglect. The administrator identified 118 residents resided in the facility.
- 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 and interview, the facility failed to ensure a medication cart was securely locked and attended to according to company policy and procedure. The administrator identified 118 residents resided in the facility.
October 31, 2024Complaint inspection · 2 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, record review, and interview, the facility failed to maintain a clean and homelike environment for two (#2 and #3) of three sampled residents reviewed for clean, comfortable, and homelike environment. The administrator identified 122 residents resided in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to ensure soiled linen were not placed on the floor to prevent the spread of infection for one of five rooms observed for clean, comfortable, and homelike environment. The administrator identified 122 residents resided in the facility.
October 21, 2024Complaint inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview, the facility failed report an allegation of abuse to OSDH for one (#5) of four sampled residents reviewed for abuse. The Administrator identified 118 residents resided in the facility.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for one (#7) of three sampled residents reviewed for lab results. The Administrator identified 118 residents resided in the facility.
- D
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 interview, the facility failed to ensure an ice machine was maintained in a sanitary manner for one of one ice machine observed. The Administrator identified 117 residents who received nourishment from the kitchen.
March 5, 2024Complaint inspection · 1 citation
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from involuntary seclusion for one (#1) of three sampled residents who were reviewed for involuntary seclusion. The administrator identified 119 residents resided in the facility.
January 29, 2024Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was not sexually abused by a staff member for one (#12) of three sampled residents reviewed for abuse. The Administrator in training identified 118 residents resided in the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation into an allegation of sexual abuse for one (#12) of three sampled residents reviewed for abuse. The Administrator in training identified 118 residents resided in the facility.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate portion sizes were served to residents. The Administrator in training identified 118 residents resided in the facility.
December 21, 2023Complaint inspection · 2 citations
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to ensure a process was in place to prevent misappropriation of Resident funds for two (#1 and #2) of three residents sampled for misappropriation of property. The Administrator identified 123 Residents resided in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, and interview the facility failed to follow physician's orders for wound care prevention for one (#8) of three sampled residents reviewed for wound care prevention. The Administrator identified 123 residents resided in the facility and the facility matrix documented four residents had pressure ulcers.
November 6, 2023Standard inspection, Complaint inspection · 5 citations
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's comprehensive assessment was completed timely for one (#86) of 24 sampled residents reviewed for comprehensive assessments. The Administrator identified 121 residents resided in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#92) of 24 sampled residents whose assessments were reviewed for accuracy. The administrator identified 121 residents resided in the facility.
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's code status was identified in their clinical record for one (#70) of 24 sampled residents reviewed for code status. The Administrator identified 121 residents resided in the facility.
- 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 and interview, the facility failed to ensure medications were secured for one of one treatment carts observed for medication storage. The facility identified 4 medication carts.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to maintain infection control during the provision of wound care for one (#92) of three sampled residents reviewed for pressure ulcers. The administrator identified 121 residents resided in the facility.
September 6, 2022Standard inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteOn 08/31/22 at 10:16 a.m., LPN #3 was asked how frequently staff screened in. They stated twice a week. They were asked what did the screening process entail. LPN #3 stated they would get their temperature checked, given a nasal swap that they swabbed themselves, and would wait on the results before the start of their shift. On 08/31/22 at 10:18 a.m., CNA #2 was observed wearing a surgical mask, and no eye protection, on memory care unit with Resident #26 (COVID-19 positive) wandering around not in their room. CNA #1 was observed wearing a surgical mask under their nose, and no eye protection, on the memory care unit. They were observed to propel a resident in a wheelchair to the dining room table, walked across memory care unit, got a bag of chips, and took the chips back to the resident, with their mask continually observed under their nose. [...]
Fire safety inspections
22 fire safety citations on file: 4 on January 21, 2025, 10 on November 6, 2023, 8 on September 6, 2022.
Every fire safety citation22 citations
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · January 21, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · January 21, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 21, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · November 6, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 6, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · November 6, 2023 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · November 6, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 6, 2022 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · September 6, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 6, 2022 · 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 6, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 6, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 6, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 6, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 6, 2022 · Corrected (the home has a date of correction)