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
1E
0F
Potential for minimal harm
0A
0B
0C
July 28, 2026Standard inspection, Complaint inspection · 2 citations
- E
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 observations, interviews and a facility policy titled, Resident Rights the facility failed to ensure a clean, safe and homelife environment. Specifically, the facility failed to maintain resident care areas and hallways in good repair and in a sanitary condition as evidence by broken and stained ceiling tiles. This affected room numbers 212, 217, 308, 315, 319, 324, 403 along with common areas and hallways on the 2nd floor, 3rd floor, and 4th floor. These failures affected seven resident rooms and three floors and had the potential to affect residents by exposing them to an environment that was not maintained in a clean, safe, and home-like condition. F584 was cited as a result of the investigation of complaint/report number 452795. Findings Include: An undated facility policy titled Resident Rights, documented the following: . 8. Safe Environment. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews, record review and review of a facility policy titled Incidents and Accidents, the facility failed to provide evidence how it was determined Resident Identifier (RI) #104 acquired bruising to the upper chest and bilateral arms on 05/24/2025; and further failed to notify the family of the bruised areas. This deficient practice affected RI #104, one of five residents sampled for accidents. Failure of the facility to investigate to determine how RI #104 acquired the bruises placed RI #104 at risk of acquiring further bruises due to no interventions being implemented to reduce the risk of RI #104 acquiring bruises to his/her body. When incidents are not investigated, underlying root causes remain unknown. F689 was cited as result of the investigation of complaint/report number 2577342. Findings Include: [...]
September 26, 2019Standard inspection · 2 citations
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interviews, and the 2017 Food and Drug Administration Food Code, the facility failed to ensure a dietary staff member did not remove hot dogs from a fork with her bare hands and give them to a resident to eat during the lunch meal on 9/26/19. This affected one resident assisted in one of three dining rooms during the lunch meal on 9/26/19.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to ensure: 1. Employee Identifier (EI) #7, Licensed Practical Nurse (LPN), did not hold a medicine cup with her ungloved hand covering the rim of the cup before giving the medication to Resident Identifier (RI) #14, and 2. EI #8, LPN, did not put her ungloved fingers inside of a plastic bag of crushed medication to be given to RI #7. These deficient practices affected RI #7 and RI #14, two of eight residents observed during medication administration.
August 23, 2018Standard inspection · 4 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, interview, and review of a facility policy titled, Care Plan - Comprehensive, the facility failed to ensure a care plan was developed for the use of a psychotropic medication. This affected Resident Identifier (RI) #81, one of nineteen residents whose care plans were reviewed. Findings Include: A review of the facility policy titled, Care Plan - Comprehensive, with a revision date of 11/28/17, revealed: . Procedure . 5. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment . RI #81 was admitted to the facility on [DATE] with a diagnosis of Adjustment Disorder with Depressed Mood. [...]
- 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 observation, interviews, review of a facility document titled Refrigerator/Freezer Temperature Log, and review of a facility policy titled Medication - Room Refrigerator, the facility failed to ensure the temperatures, on the two-hundred hall Medication Refrigerator Daily Log, were routinely checked and recorded. This affected one of three medication room refrigerators in the facility. Findings Include: A review of a facility policy titled Medication - Room Refrigerator, with a revised date of 02/01/2015, documented: .Procedure . 2. The charge nurse or designee shall monitor and record the temperature for the refrigerator . each shift . [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interviews and record review, this facility failed to ensure a licensed nurse accurately documented the nebulizer mask and tubing were changed as was documented on the Medication Administration Record (MAR) of Resident Identifier (RI) #58. This deficient practice was identified for one of 3 sampled residents with nebulizer masks/tubing. Findings Include: Resident Identifier #58 was admitted to facility on 06/20/18 with a readmit date of 07/2/18. The August, 2018, MAR revealed the facility is to change the nebulizer tubing and mask every seven days on 11-7 shift and as needed and the oxygen tubing is to be changed every week on Sunday on the 11-7 shift and as needed. This MAR incidates that EI #7, LPN initialed on 08/12/18 and 08/19/18 that the nebulizer mask and tubing had been replaced. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews and review of medical records as well as review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, this facility failed to ensure that Resident Identifier (RI) #58's nebulizer mask and tubing was changed in accordance with the order listed on the Medication Admnistration Record and that contact precautions were followed when care was being provided for RI #338, a resident on contact precautions. This affected two of 3 residents reviewed for infection control practices and precautions. Findings Include: 1. Resident Identifier #58 was admitted to facility on 06/20/18 with a readmit date of 07/2/18. [...]
Fire safety inspections
16 fire safety citations on file: 9 on July 28, 2026, 2 on September 26, 2019, 5 on August 23, 2018.
Every fire safety citation16 citations
- F
Install an approved automatic sprinkler system.
K 351 · July 28, 2026 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · July 28, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 28, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 28, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 28, 2026 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 28, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · July 28, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 28, 2026 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · July 28, 2026 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · September 26, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 26, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 23, 2018 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 23, 2018 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · August 23, 2018 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 23, 2018 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 23, 2018 · Corrected (the home has a date of correction)