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
1E
2F
Potential for minimal harm
0A
0B
0C
July 4, 2025Standard inspection, Complaint 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, facility document review, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to discard expired foods; properly store foods in a refrigerator and freezer; maintain cold foods on the tray line to at least 41 degrees Fahrenheit (F); and wash, rinse, and sanitize dishes according to manufacturer instructions. These deficient practices had the potential to affect all residents who received food from the kitchen.
- E
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on record review, interview, and facility document and policy review, the facility failed to provide access to resident funds on an ongoing basis. This had the potential to affect 62 of 90 residents whose personal funds were managed by the facility.
- 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 record review, interview, and facility document and policy review, the facility failed to ensure resident rights were protected, and efforts were made to resolve a grievance for 1 (Resident #64) of 3 residents reviewed for grievances.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to protect the resident's right to be free from verbal abuse perpetrated by staff for 2 (Resident #56 and Resident #39) of 11 sampled residents reviewed for abuse.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure residents were free from any physical restraint not required to treat the resident's medical symptoms, which affected 1 (Resident #299) of 1 resident reviewed for use of restraints.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure staff reported allegations of staff-to-resident abuse to administration within two hours for 2 (Resident #37 and Resident #300) of 11 sampled residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to immediately put protective measures in place to prevent further potential abuse following an allegation of staff-to-resident verbal abuse for 1 (Resident # 37) of 11 sampled residents reviewed for abuse. The facility also failed to have evidence that allegations of abuse and/or neglect were thoroughly investigated for 2 (Resident #300 and Resident #14) of 11 sampled residents reviewed for abuse.
September 19, 2019Standard inspection · 1 citation
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews and a review of the facility's policy titled, Dishwashing Procedures, the facility failed to ensure two pans and serving trays were allowed to air dry before storage. This had the potential to affect all 89 residents being served food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) signed by the Director of Nursing and dated 9/17/2019, indicated the facility had a total of 89 residents.
August 8, 2018Standard inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview and review of a policy tilted Abuse Policy the facility failed to ensure an allegation of sexual abuse and verbal abuse were reported to the State Agency within 2 hours. This affected 2 of 5 abuse records reviewed during the survey and Resident Identifier's (RI) #62 and RI #141. Findings Include: Review of a policy tilted Abuse Policy with an effective date of June 2018 documented: .Reporting .1. Any allegation of abuse within two hours . 1) On 8/8/18 at 11:00 a.m., the surveyor reviewed the online incident report involving an allegation of sexual abuse concerning RI #62. The facility became aware of the incident on 5/6/18 at 3:11 p.m. and did not report the incident until 5/6/18 at 6:31 p.m. On 8/8/18 at 12:38 p.m., an interview was completed with Employee Identified (EI) #1, Administrator, Abuse Coordinator. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on Record Review and Interview the facility failed to ensure Resident Identifier (RI) # 9's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/18/18 documented the use of oxygen. This affected 1 of 19 residents whose MDS's were reviewed for accuracy. Findings Include: RI # 9 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with acute exacerbation. A review of RI # 9's Physician Orders documented: .O2(oxygen) @ 2L(liters)/M(minute) per NC (nasal canal) PRN (as needed) .every day and night shift .4/16/18 . A review of RI # 9's Significant Change MDS with an ARD of 5/18/18 on 8/8/18 at 4:00 p.m. did not document the use of oxygen in Section O. An interview was conducted with Employee Indentifer (EI) # 4, Registered Nurse (RN) MDS Coordinator on 8/8/18 at 4:35 p.m. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, [NAME] & [NAME] Eighth Edition and [NAME] and [NAME], Fundamentals of Nursing, Ninth Edition, the facility failed to ensure Resident Identifier (RI) # 9's nebulizer machine tubing and face mask were bagged after use and the medication cup and face mask were changed out weekly. This affected 1 of 1 resident sampled who received nebulizer treatments. Findings Include: A review of [NAME] & [NAME] 8th Edition, Chapter 21, Page 528 documented: .Proper storage reduces transfer of microorganisms . A review of of [NAME] and [NAME], Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated . [...]
Fire safety inspections
9 fire safety citations on file: 5 on July 4, 2025, 2 on September 19, 2019, 2 on August 8, 2018.
Every fire safety citation9 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 4, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · July 4, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 4, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 4, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · July 4, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 19, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · September 19, 2019 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 8, 2018 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 8, 2018 · Corrected (the home has a date of correction)