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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
1E
0F
Potential for minimal harm
0A
0B
0C
September 18, 2025Standard inspection, Complaint inspection · 8 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP), during a perineal care observation for I of 1 sampled resident, Resident #7, reviewed for perineal care, for 1 of 4 sampled residents reviewed for PEG tube, Resident #7, during a percutaneous endoscopic gastrostomy (PEG) tube care observation; failed to perform hand hygiene, and failed to change damaged PPE gloves during a bolus feeding observation for 1 of 4 sampled residents reviewed for tube feeding, Resident #9; failed to follow their policy for hand hygiene during a medication administration for 1 of 6 medication administration observations, Resident # 16; failed to initiate an EBP nursing care plan for 1 of 6 sampled residents for medication administration, Resident #16; [...]
- 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 10 of 60 rooms (room [ROOM NUMBER]-B, #102-B, 105-B, #110, #116, #120, #206, #210, #212, and #214).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews, record review and the review of the facility policy, the facility failed to report a resident's unwitnessed fall with an injury of unknown source for 1 of 1 sAMPLED resident reviewed for Falls, Resident #77.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interviews and the facility policy review, the facility failed to initiate and conduct a complete and thorough investigation to an unwitnessed fall resulting in an injury of unknown source of origin for 1 of 1 sampled resident for Falls (Resident #77).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow physician orders for weekly weight monitoring for 1 of 5 sampled residents reviewed for respiratory care, Resident #34. Based on observations, interviews, and record reviews, the facility failed to follow the professional standards of nursing practice for not following physician orders by ensuring that blood pressure and heart rate were monitored before the administration of a beta blocker medication for 1 of 6 medication administration reviews, affecting Resident #100; and failed to follow their own policy by ensuring the right dosage and right route based on the six rights of medication administration were followed for 1 of 5 unnecessary medication reviews, affecting Resident #7.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, record reviews, policy reviews, and interviews, the facility failed to weigh a newly admitted resident weekly for 4 weeks in a row, for 1 of 4 sampled residents, Resident #105, reviewed for nutrition; and failed to implement interventions and monitoring to ensure adequate nutrition for 1 of 4 residents sampled residents, Resident #125, reviewed for Tube Feeding.
- 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 regarding oxygen therapy for 2 of 5 sampled residents reviewed for respiratory care, Resident #34 and Resident #37; failed to follow the professional standards of nursing practice by allowing a Certified Nurse Assistant (CNA) to administer and change the sterile water bottles use for oxygen humidification of oxygen concentrators for 3 of 5 sampled residents reviewed for respiratory care, Resident #34, Resident #109, Resident 107; and failed to ensure proper care and management of oxygen therapy equipment for 3 of 5 sampled residents reviewed for respiratory care, Resident #34, Resident #37, and Resident #109.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide foods consistent with dietary orders for 2 of 11 residents who had physician orders for puree texture diets.
May 16, 2024Standard inspection · 0 citations
March 2, 2023Standard inspection · 2 citations
- 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 observations, interviews, and record review, the facility failed to provide showers per resident preferences for 2 of 2 sampled residents reviewed for showers (Resident #62 and 80).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the physician's orders were followed as ordered for 1 of 10 sampled residents (Resident #16) during medication administration observation review as evidenced by performing Resident #16's blood glucose test and administering insulin after a meal instead of before meal as per physician order.
Fire safety inspections
7 fire safety citations on file: 4 on September 18, 2025, 1 on May 16, 2024, 2 on March 2, 2023.
Every fire safety citation7 citations
- F
Provide primary/alternate means for communication.
E 32 · September 18, 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 · September 18, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 18, 2025 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 18, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 16, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 2, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 2, 2023 · Corrected (the home has a date of correction)