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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
1E
0F
Potential for minimal harm
0A
1B
0C
December 11, 2025Standard inspection, Complaint inspection · 4 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, the facility failed to clean a circulatory fan cover in the walk-in refrigerator and prevent condensation from forming and dripping onto stored food, which resulted in water standing on the floor of the walk-in refrigerator. This issue was identified for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect food served to some of the 103 residents residing in the facility.
- D
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, record review, and interviews with resident and staff, the facility failed to maintain a clean shower room for 2 of 3 shower rooms observed. The facility also failed to maintain a wheelchair in good repair for 1 of 4 residents reviewed for mobility devices (Resident #99).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately complete a comprehensive assessment in the area of diagnoses for 1 of 22 resident assessments reviewed (Resident #10).
- 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, record review, and staff interviews, the facility failed to store ammonium lactate lotion (prescription-strength lotion), antifungal powder, and betadine solution (topical antiseptic solution) in a locked cart. These items were found unsecured on a resident's bedside table. This occurred for 1 of 5 residents reviewed for medication storage (Resident #64). Additionally, the facility failed to date one opened bottle of Latanoprost after it was opened and failed to store one bottle of Latanoprost in accordance with manufacturer's storage guidelines for 1 of 5 medication carts (600 Hall).
September 27, 2024Standard inspection, Complaint inspection · 4 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interviews with resident and staff, the facility failed to ensure dependent residents could access the light switch located behind the bed for 1 of 1 resident reviewed for accommodation of needs (Resident #2).
- 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 record review, observation and staff interviews the facility failed to follow a physician order to apply a splinting device for 1 of 2 residents (Resident #14) reviewed for range of motion.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to check a finger-stick blood sugar (FSBS) for 1 of 6 residents reviewed for unnecessary medications (Resident #311).
- 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 observations, staff interviews and record reviews, the facility failed to date a bottle of eye medication after it was opened and failed to discard 2 bottle of expired eye medications from the medication cart as specified by manufacturer's guidelines for 2 of 5 medication carts observed during medication storage checks (100 hall and 700 hall medication carts).
May 25, 2023Standard inspection · 6 citations
- G
Provide or obtain dental services for each resident.
Inspectors wroteBased on record review resident interview and staff interviews, the facility failed to provide expedited dental care for a resident with broken dentures for 1 of 1 resident reviewed for dental services (Resident #12). As a result of Resident #1 not having her dentures she was unable to chew her physician ordered diet which resulted in decreased intake and weight loss.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 3 of 21 residents reviewed (Resident #20, Resident #21, and Resident #60).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record review, resident, staff and Nurse Practitioner interviews, the facility failed to apply compression stockings as ordered by the Nurse Practitioner for 18 days. The failure occurred for 1 of 1 resident (Resident #125) reviewed for the provision of care according to professional standards.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, staff and Medical Director interviews the facility failed to comply with oxygen orders for 1 of 2 residents reviewed for respiratory care (Resident #43).
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 10 rooms on the 300-hall reviewed for privacy.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident reviewed for dialysis while a resident (Resident #17) and 1 of 3 residents reviewed for discharge status (resident #70).
Fire safety inspections
23 fire safety citations on file: 11 on December 11, 2025, 5 on September 27, 2024, 7 on May 25, 2023.
Every fire safety citation23 citations
- E
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · December 11, 2025 · Corrected (the home has a date of correction)
- D
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 · December 11, 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 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · December 11, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 11, 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 · September 27, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 27, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 27, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 27, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 27, 2024 · 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 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 25, 2023 · Corrected (the home has a date of correction)