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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
6E
1F
Potential for minimal harm
0A
0B
0C
January 8, 2026Standard inspection · 2 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that food items stored in the dry storage area were labeled with the item description (handwritten or manufacturer's label) and included the date opened, and the use by/consume by or expiration date. The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents. These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the dry storage area on 01/06/2026 at 8:15 a.m. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four (LVN A) staff members and four of six residents (Residents #22, #65, #67, & #84) reviewed for infection control procedures. LVN A failed to perform hand hygiene after direct contact with Residents #22, #65, #67, and #84 while serving meals in the dining room. This failure could place residents at risk for healthcare associated cross contamination and infections.
October 2, 2024Standard inspection, Complaint inspection · 5 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, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure ice machine #1 and #2's filters and vents were free from dirt and dust. 2. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', discard by or expiration dates. 4. The facility failed to ensure Handwashing sink #1's garbage receptacle contained only paper towels. 5. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 (LVN A, and MA B) staff members and 4 of 6 residents (Residents #13, #28, #40, and #72) reviewed for infection control procedures. LVN A failed to disinfect the blood pressure cuff (machine used for checking blood pressure) in between blood pressure checks for Residents #28, and #72. MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #13 and #40. This failure could place residents at risk for cross contamination and infections.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (two unused halls) of three halls (Halls 400, 500, and 600) and the nurse's station, private dining room, kitchen, the unused dining room next to private dining room, and main dining room reviewed for pest control program. The facility had live fruit flies in areas of the facility including the nurse's station, Halls 400, 500, 600, nurse's station, private dining home, unused dining room next to the private dining room, lobby, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 2 of 29 opportunities during medication pass resulting in an 6 percent (6%) error rate for two (Residents #13, and #65) of 6 residents observed for medication pass. 1. MA B failed to administer Resident #13's Cranberry tablets 500mg (for urine retention) due to not having the tablets available. 2. MA B failed to administer Resident #65's Solonpas (Central nervous system, anti-inflammatory agent, for pain) to bilateral knees one time a day. MA B provided the patches to the resident and left the room, not observing if the resident applied them to her knees correctly. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a decreased health status.
- 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, interview, and record review, the facility failed to provide a locked and permanently affixed compartment for storage of all controlled drugs for 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the lockbox in the medication room refrigerator was locked that contained eight syringes of Ativan Benadryl cream (schedule IV, controlled medication). This failure could place residents receiving medication at risk for drug diversion or misuse of medications.
September 13, 2023Standard 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 observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 (Residents #3, #30,#36, and #38) of 48 residents observed for wheelchairs, in that: The facility failed to properly maintain wheelchairs for Residents #3, #30, #36, and #38. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriately be cleaned due to the cracked and exposed foam. There was a posed safety problem as the cracked arm rest pads could cause injury to the residents. These failures could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Residents #24, #127, and #128) of five residents reviewed for infection control. RN C failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) in between resident use, for Residents #127, and #24. LVN D failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) after resident use, for Resident #128. This failure could place residents at-risk of cross contamination which could result in infections or illness.
Fire safety inspections
14 fire safety citations on file: 2 on January 8, 2026, 6 on October 2, 2024, 6 on September 13, 2023.
Every fire safety citation14 citations
- E
Have proper medical gas storage and administration areas.
K 923 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 2, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 2, 2024 · 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 · October 2, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 13, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 13, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 13, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 13, 2023 · 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 · September 13, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · September 13, 2023 · Corrected (the home has a date of correction)