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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
20D
5E
1F
Potential for minimal harm
0A
0B
0C
August 28, 2025Standard inspection · 5 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of facility policy, the facility failed to timely identify the resident's pressure until it reached an advanced stage and failed to ensure pressure ulcer preventions consistent with professional standards of practice were in place. This resulted in Actual Harm to Resident #55 who was at risk for pressure ulcers and the facility found Resident #55's avoidable pressure ulcer as a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed). This affected one (Resident #55) of two residents reviewed for pressure ulcers. The facility census was 80.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and review of facility policies, the facility failed to serve food in a manner that prevented contamination. This affected seven (Residents #13, #19, #35, #45, #54, #86, and #87) observed for room tray service and had the potential to affect all residents in the facility except Residents #4, #9, #12, and #88 who do not receive food from the kitchen. The facility census was 80.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review, resident and staff interview, observation, and review of facility policy, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's care needs. This affected two resident (#2 and #27) of 18 residents reviewed for MDS accuracy. The facility census was 80.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to regularly monitor a resident's weight according to physician orders and facility policy. This affected one (Resident #55) of one resident reviewed for nutrition. The facility census was 80.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure physician orders were obtained for use of oxygen therapy and Bilevel Positive Airway Pressure (BIPAP) use. This affected one (#27) of one resident reviewed for oxygen and BIPAP use. The facility identified 29 residents who require the use of oxygen and six residents who require the use of BIPAP machine. The facility census was 80.
July 7, 2025Complaint inspection · 2 citations
- 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 record review, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure Resident #16 who had a indwelling catheter received the appropriate treatment and services related to a urinary tract infection (UTI). This affected one (#16) of six residents reviewed for UTIs. The facility census was 76.
- 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, record review and staff and resident interview, the facility failed to ensure medications were administered appropriately and not left unsecured in a resident room. This affected one (#15) of one resident reviewed for medications. The facility census was 76.
March 13, 2025Complaint inspection · 4 citations
- E
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, staff interview, and review of the menu spreadsheet, revealed the facility failed to provide adequate portions of food. Additionally, the facility failed to ensure adequate food was prepared to provide all residents with an appropriate portion of food. This had the potential to affect all residents in the facility except Resident #92 who received no food by mouth. Finally, the facility failed to ensure residents on a pureed diet received all items on the menu. This affected five (#13, #24, #39, #42, and #94) residents on a pureed diet. The facility census was 90.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, staff interview, record review, menu review, and recipe review, the facility failed to ensure residents on a mechanical soft diet received appropriately textured food. This had the potential to affect 12 (#11, #15, #28, #29, #38, #44, #48, #55, #68, #69, #82 and #97) residents on a mechanical soft diet. Additionally, the facility failed to ensure residents received appropriate food textures and thickened beverages with their meals. This affected two (#24 and #42) residents on a pureed diet observed during meal service. The facility census was 90.
- 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, staff interview, and policy review, the facility failed to ensure staff practiced proper hand hygiene during meal service. Additionally, the facility failed to ensure food was covered during delivery to resident rooms. This had the potential to affect all residents in the facility except Resident #92 who received no food from the kitchen. Additionally, the facility failed to ensure staff practiced proper sanitation practices when handling resident meal trays. This affected one (Resident #101) resident's tray observed during meal service. The facility census was 90.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on record review, staff interview, review of email correspondence, and policy review, the facility failed to ensure resident representatives received copies of medical records in a timely manner. This affected two (#12 and #72) of two residents reviewed for medical record requests. The facility census was 90.
July 1, 2024Complaint inspection · 1 citation
- J
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, medical record review, staff interviews, interviews with the Local Health Department (LHD), review of hospital medical records, review of water sample testing reports, review of chlorine level logs, review of the facility's water management plan and review of the facility's water treatment program, the facility failed to implement immediate action to protect residents from Legionella (bacteria that causes a severe form of pneumonia with exposure generally from droplets of water) when a water sample test detected Legionella on the 300 Hall on 06/03/24. This resulted in Immediate Jeopardy and serious life-threatening harm and the potential for additional negative health outcomes and/or death when one resident (#01), who resided on the 100 Hall, developed respiratory symptoms and experienced a change in condition on 06/13/24. [...]
May 2, 2024Complaint inspection · 1 citation
- 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, medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure medications were kept secure at all times. This affected one (#17) of three residents observed for medication storage. The facility census was 85.
November 2, 2023Complaint inspection · 4 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, resident interview, staff interview, hospital record review, review of facility incident report, and review of facility policy, the facility failed to report an injury of unknown origin to the state agency for Resident #23 and failed to report a resident to resident incident to the state agency for Resident #84. This affected two (#23 and #84) of three reviewed for abuse and neglect. The facility census was 84.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased medical record review, resident interview, staff interview, review of hospital records, and review of facility policy, the facility failed to complete a thorough investigation after an injury of unknown origin was identified. This affected one (#23) of three residents reviewed for injury. The facility census was 84.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received showers according to their schedule and as needed. This affected three (#28, #87 and #88) of three residents reviewed for Activities of Daily Living (ADLs). The facility census was 84.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on review of physician orders, observations, resident interviews, staff interviews, and review of dietary spreadsheets, the facility failed to provide therapeutic diets according to physician order. This affected two (#51 and #28) of three residents reviewed for diabetic (carbohydrate consistent - CCD) diet orders, with the potential to affect 19 (#2, #5, #8, #10, #13, #16, #18, #22, #31, #38, #40, #42, #45, #48, #53, #69, #78, #80, and #89) additional residents identified by the facility with physician ordered CCD diets. The facility census was 84.
May 10, 2023Standard inspection · 6 citations
- E
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 record review, policy review, and family and staff interview, the facility failed to conduct quarterly care conferences routinely. This affected seven (Residents #28, #32, #46, #56, #63, #70, and #71) of 10 residents reviewed for care planning. The facility census was 91.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on medical record review, review of Resident Council meeting minutes, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received showers per the resident's preference. This affected two (Residents #32 and #76) of two residents reviewed for choices. The facility census was 91.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to ensure care and maintenance was provided for a midline catheter. This affected one (#30) of one residents reviewed for peripheral venous catheters. The facility census was 91.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, resident and staff interview, and policy review, the facility failed to ensure a resident was provided with physician ordered wound healing supplement. This affected one resident (#28) of three residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. The facility census was 91.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure a fistula was routinely monitored for a resident on dialysis. This affected one (#21) of one resident reviewed for dialysis. The facility identified four residents who received dialysis. The facility census was 91.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure the medications administered were documented accordingly in the medical record. This affected one (Resident #42) of five residents reviewed for medications. The facility census was 91.
November 4, 2021Standard inspection · 5 citations
- F
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Inspectors wroteBased on review of medical record, family and staff interview, review of facility correspondence, and policy review, the facility failed to allow residents to have visitation by family members at any time. This affected one (#55) resident who's family was interviewed and had the potential to affect all 81 residents residing in the facility.
- 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 review of the medical record, resident representative interview, and staff interview, the facility failed to hold care conferences and failed to invite residents or their representatives to care conferences. This affected two (#36 and #68) of 20 residents reviewed. The facility census was 81.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on resident record review, observation, staff interview, and review of facility policy, the facility failed to ensure activity preferences and physician orders were followed for one (#53) out of 20 residents reviewed. The facility census was 81.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to follow physician orders for fluid restrictions for one (#18) of one resident reviewed for dialysis. The facility had two residents receiving dialysis. The facility census was 81.
- 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, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were stored and removed from use per manufacturer instructions. This affected one (#44) of 21 residents with medications stored in the 100 Hall medication cart. The census was 81.
Fire safety inspections
16 fire safety citations on file: 5 on August 28, 2025, 8 on May 10, 2023, 3 on November 4, 2021.
Every fire safety citation16 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 28, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 10, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 10, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 10, 2023 · 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 · May 10, 2023 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 4, 2021 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 4, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 4, 2021 · Corrected (the home has a date of correction)