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 14 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
1B
0C
June 26, 2025Standard inspection · 7 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on policy review, record review and interviews, the facility failed to monitor the temperatures for 2 of 4 sampled residents, Resident #43 and Resident #98, who were being treated with an antibiotic for respiratory infection, as evidenced by no temperatures were documented.
- 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 review of policy and procedure, observation, interview and record review, the facility failed to ensure that it followed the physician's order for splints in order to prevent further decline in range of motion (ROM) for 2 of 2 sampled residents observed, Resident #53 and Resident #44.
- 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 observations interviews and record reviews, the facility failed to follow the professional standards of care, as evidenced by failure to verify gastrostomy placement, for 1 of 5 sampled residents on tube feedings, Resident #25.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy for proper tracheostomy care for 1 of 3 resident (Resident #23), and failed to perform pre and post respiratory assessment for 1 of 3 sampled residents reviewed for tracheostomy care (Resident #695); failed to obtain written and care treatment orders for 1 of 5 sampled residents, Resident #53; failed to obtain oxygen therapy orders for 1 of 5 sampled residents, Resident #84; failed to perform pre and post assessments including vital signs for 1 of 5 sampled residents, Resident#695; and failed to properly store and maintain respiratory equipment and supplies for 3 of 5 sampled residents reviewed for oxygen therapy, Resident #31, Resident #6, and Resident #25.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, record review and interviews, the facility failed to provide accurate fluid consistency per the physician orders for thickened liquids for 1 of 3 sampled residents, Resident #408, as evidenced by the resident was provided liquids in the consistency that was not ordered for her.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions, and to prevent foodborne illnesses during two of the two visits to the main kitchen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain the infection control standards in the laundry room; failed to maintain a sanitary environment during tube feeding for 1 of one sampled resident, Resident #95; failed to maintain the infection control standards for Enhanced Barrier Precautions (EBP), for 2 of 64 sampled residents, Resident #19 and Resident #88; and failed to follow the Center for Disease Control and Prevention (CDC), EBP guidelines for 4 of 64 sampled residents, that included 56 adults and 8 pediatrics, Resident #31, Resident #6, Resident #23, and Resident #25.
March 28, 2024Standard 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 observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included failure to hold hot and cold foods at the regulatory temperature of 41 degrees Fahrenheit (F) or below, or 135 degrees F or higher.
- 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 housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 12 of 30 resident rooms, 1 of 1 clean linen storage rooms, and 1 of 1 clean nursing wound storage supply room located on the Second Floor Geriatric Unit.
- 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, interview, and record review, the approved facility menu was not being followed for physician ordered diets that included: Regular Diet (total 7 residents - included sampled Residents #9 and #85), Soft & Bite Sized Level 6 (total 7 residents - included sampled Resident #2), and Moist & Minced Level 5 (included Resident #3).
January 12, 2023Standard inspection · 4 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interviews, observations and record review, the facility failed to provide nutritional assessments and interventions promptly and follow up on monthly weights for 2 of 4 sampled residents reviewed for nutrition, Residents #17, and #7.
- 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 observation, interview and record review, the facility failed to maintain aspiration precautions for a resident who was being fed by enteral means (tube feeding), as evidenced by staff not consistently keeping the head of the bed elevated while the tube feeding was running for Resident #77; and failed to follow Practitioner orders for tube feeding (Resident #98), for 2 of 6 sampled residents reviewed for tube feeding.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of policy and procedure, observation, record review and interview, the facility failed to ensure that it obtained a current, written physician's order for Oxygen therapy treatment for 2 of 2 sampled residents observed, Resident #358 and Resident #6.
- B
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and review of policy and procedure, the facility failed to ensure that it maintained clean and sanitary dryer drums in the laundry area for 2 of 3 dryers observed.
Fire safety inspections
4 fire safety citations on file: 2 on June 26, 2025, 1 on March 28, 2024, 1 on January 12, 2023.
Every fire safety citation4 citations
- D
Provide properly protected cooking facilities.
K 324 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 26, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 28, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 12, 2023 · Corrected (the home has a date of correction)