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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
3E
0F
Potential for minimal harm
0A
0B
0C
May 28, 2026Complaint inspection · 1 citation
- 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 facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate treatment and services to assist a resident in maintaining or improving bowel and bladder continence to the extent possible for one of two sampled residents reviewed for continence care. (Resident R7)
July 17, 2025Standard inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record reviews, review of facility investigations and grievance logs, it was determined that the facility failed to report allegation for neglect and misappropriation for two of 18 residents reviewed (Resident R19 and R51).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the timely acquisition and administration of a prescribed pain medication to meet the needs of one of four residents reviewed for pain management (Resident R64).
September 12, 2024Standard inspection · 6 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to provide necessary services to maintain adequate grooming for dependent residents for three of 13 residents reviewed (Resident R11, R22 and R95).
- E
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 personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for three of three personnel files reviewed related to skills competencies evaluations (Employees E8, E9, E10).
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for two of two residents reviewed (Resident R11, and Resident R38).
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident timely received the necessary behavioral health care to attain or maintain the highest practicable mental and psychosocial well-being for one of 13 residents sampled (Resident 38).
- 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, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food stored in the refrigerator, freezer and resident's room was stored by professional standards for food service safety.
- 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 interview with staff, it was determined that the facility did not ensure that physician orders were recorded completely and accurately for two of 16 records reviewed (Residents R96 and R145).
December 14, 2023Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of clinical records, review of facility policy and procedure, review of facility documentation and interviews with staff, it was determined that the facility failed to conduct a complete and thorough injury of unknown origin investigation regarding a hip fracture for one of 3 residents reviewed. (Resident CL1).
November 17, 2023Standard inspection · 10 citations
- D
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 Resident Council meeting, resident interviews, review of facility policy and procedures, it was determined that the facility failed to ensure that grievance forms were available and accessible to residents' on the nursing units for five of 14 sample residents reviewed (Residents R201, R197, R2, R23, R4).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, review of clinical records, review of facility policy and interviews with staff, it was determined that the facility failed to ensure a resident received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers and continue treatments to prevent new from forming for one of 14 resident records reviewed. (Resident R20).
- 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, clinical record, and staff interview, it was determined that the facility failed to ensure that the resident received enteral feedings as prescribed and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of one resident sampled (Resident 17).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide to ensure that one of 19 residents reviewed was properly access for pain and provided effective pain management. (Residents R190).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on review of clinical record and review of facility policy, it was determined that the facility failed to ensure residents who require dialysis treatments and prescribed medication received such services, consistent with professional standards of practice for one of 14 resident clinical records reviewed (Resident R11).
- D
Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to post daily nurse staffing data on each nursing unit on November 15, 20023, on both nursing floors of the facility. (First floor and Second Floor)
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure that a clinical rationale failed to provide the duration of a hypnotic medication for two of five residents reviewed (Resident R3 and Resident R87).
- D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast in three of three nursing units. (A, B, and C nursing units).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure the physician notes were was accessible in one of 14 resident clinical records reviewed (Resident R14).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of three nursing units (A nursing unit).
Fire safety inspections
10 fire safety citations on file: 6 on July 17, 2025, 4 on September 12, 2024.
Every fire safety citation10 citations
- F
Develop Emergency Preparedness policies and procedures.
E 13 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Address patient/client population and determine types of services needed.
E 7 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Conduct testing and exercise requirements.
E 39 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 17, 2025 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 12, 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 12, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · September 12, 2024 · Corrected (the home has a date of correction)