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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
0E
1F
Potential for minimal harm
0A
0B
0C
June 24, 2026Standard inspection · 0 citations
April 3, 2025Standard inspection · 5 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to educate and provide written information to residents regarding a right to formulate an advanced directive for 4 of 24 residents (Residents #24, #36, #75, and #239) reviewed.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of physical restraints for 1 of 1 (Resident #29) sampled residents reviewed for restraints.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on the facility's Clinical Skills Fair Guide, observation, and interview, the facility failed to use proper supplies when 1 of 5 nurses (Licensed Practical Nurse (LPN) A) administered medication from a flex pen during medication administration.
- 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 policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 2 of 57 (Residents #23 and #47) resident occupied rooms.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on the facility Infection Control Guide, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 nurse (Licensed Practical Nurse (LPN C) failed to wear Personal Protective Equipment (PPE) in an enhanced barrier precautions room.
June 16, 2021Standard inspection · 3 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 policy review, observation, and interview the facility failed to ensure food was stored and distributed in a manner to prevent the spread of infection when unlabeled and expired foods were found in a refrigerator in the Kitchen, and when 4 of 21 staff members (Certified Nursing Assistant (CNA) #1 and #3, Licensed Practical Nurse (LPN) #3 and Nursing Assistant (NA) #1) touched residents' food, failed to appropriately sanitize their hands, and failed to wear appropriate Personal Protective Equipment (PPE) during meal service. This had the potential to affect the 96 of the 97 residents who had received a tray from the Kitchen.
- 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 policy review, medical record review, observation, and interview, the facility failed to ensure feeding syringes were properly labeled for 2 of 4 sampled residents (Resident #47 and #298) reviewed for tube feedings.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #2) failed to administer insulin within the proper time frame related to meals for Resident #24. The failure to provide a substantial meal or snack within 15 minutes of insulin administration resulted in a significant medication error.
Fire safety inspections
8 fire safety citations on file: 2 on June 24, 2026, 3 on April 3, 2025, 3 on June 16, 2021.
Every fire safety citation8 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 24, 2026 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 24, 2026 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 3, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 3, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 3, 2025 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 16, 2021 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 16, 2021 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 16, 2021 · Corrected (the home has a date of correction)