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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
2E
1F
Potential for minimal harm
0A
0B
0C
September 5, 2025Standard inspection · 7 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner, putting 147 residents who received meals from the kitchen (12 residents received nutrition via feeding tubes) out of 159 total residents at potential risk for foodborne illness. Specifically, failures included: improper freezer temperatures, a lack of functioning thermometers in the refrigerators/freezers, improper concentration of sanitizer solutions, uncleanable surfaces due to rust, not labeling foods removed from original packaging with the identification of the contents, unclean microwaves in the pantries, improperly maintained equipment such as refrigerators in the nursing pantries, an ice machine was unclean on the inside box where ice was made and stored, and tray line food holding temperatures were outside of safe temperature ranges.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to allow one out of 33 sampled residents (Resident (R)15) to exercise her right to go to the day room to attend activities. R15 was not allowed to co-mingle with other residents in the activity room after she sustained an infection. R15 was currently on enhanced barrier precautions which did not dictate that the resident could not leave her room and attend activities in the day room or socialize there. This created the potential for R15 to experience isolation and the inability to enjoy previous activities in which she had participated.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one resident and family member out of 32 sampled residents (Resident (R)103) were invited to the quarterly care plan meeting. The facility's practice did not include inviting residents or families to quarterly care plan meetings. This created the potential for residents/families to lack information regarding care and services provided and lack the opportunity to provide input into care provided.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure written notice of the facility's bed hold policy and/or transfer notices that contained all necessary information were provided to three of four residents and/or representatives (Resident (R) 1, R22, and R7) reviewed for transfer notices out of a total sample of 32. This failure had the potential for the resident and/or representative not to have knowledge of where and why a resident was transferred, how to appeal the transfer, or to be knowledgeable of the facility's bed hold policy.
- 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 observation, interview, record review, and policy review, the facility failed to ensure one out of one sample residents reviewed for range of motion (ROM) (Resident (R) 58) out of a total sample of 32 residents, had an elbow splint/hand roll applied in accordance with physician's orders. This created the potential for R 58 to experience a worsening of her contracted left arm/hand.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure laboratory results were followed up on in a timely manner for one of three sampled residents (Resident (R) 58) reviewed for a urinary tract infection (UTI) out of a total sample of 32. R58's Urinalysis and Culture and Sensitivity (C & S) results revealed she may have had a urinary tract infection. There was no documentation of follow up indicating the Physician was notified of the results and no documentation of whether the physician wanted to treat the infection until the surveyor asked about it nine days later. This created the potential for R58 to experience a UTI without treatment.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one sampled resident (Resident (R)103) reviewed for dental services out of a total sample of 32 was scheduled for dental services within three days and in accordance with facility policy after her dentures were lost on 05/25/25.
June 6, 2024Standard inspection · 2 citations
- E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to a.) ensure the physician signed and dated monthly medication orders and b.) ensure the physician or the non-physician practitioner (NPP) performed face-to-face monthly visits. The deficient practice was identified for 19 of 32 residents reviewed (#29, 129, 22, 51, 65, 121, 97, 116, 53, 10, 101, 11, 2, 69, 33, 80, 138, 75, 118) and occurred over a 6 month period. The deficient practice was evidenced by the following. 1. A review of the hybrid medical record for Resident #29 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January, February, March, April, or May 2024. 2. [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, it was determined that the Consultant Pharmacist (CP) failed to report irregularities found in the medical records to the facility. This deficient practice was observed for the following resident. On 6/4/24 at 12:21 PM, the surveyor reviewed the hybrid medical record (paper and electronic) for Resident #83. The resident's admission Record (AR) reflected that the resident was admitted with diagnoses including but not limited to Hypertension (elevated blood pressure) and Gastrostomy (G-tube) (an opening into the stomach from the abdomen, for the introduction of food or medications). [...]
August 11, 2022Standard inspection · 2 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain the cleanliness of the oxygen concentrator filter, change nasal cannula tubing, and transfer orders from the hospital to the residents Electronic Medical Record (EMR), for one of two residents (Resident (R) 120), sampled for respiratory care. This deficient practice increased the risk for infection in a resident that had respiratory distress.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, record review, review of the Centers for Disease and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure that one Resident(R)111, of five residents sampled for immunization reviews, were offered and given the option to receive or decline an additional pneumonia vaccine.
Fire safety inspections
17 fire safety citations on file: 4 on September 5, 2025, 3 on June 6, 2024, 10 on August 11, 2022.
Every fire safety citation17 citations
- F
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 · September 5, 2025 · Corrected (the home has a date of correction)
- F
Have exits that are accessible at all times.
K 271 · September 5, 2025 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · September 5, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · September 5, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 6, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 11, 2022 · Corrected (the home has a date of correction)
- F
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 · August 11, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 11, 2022 · Corrected (the home has a date of correction)
- F
Install properly constructed and protected linen or trash chutes.
K 541 · August 11, 2022 · 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 11, 2022 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 11, 2022 · Corrected (the home has a date of correction)