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
2G
0H
0I
Potential for more than minimal harm
3D
1E
3F
Potential for minimal harm
0A
0B
0C
November 21, 2025Standard inspection · 2 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 follow the food storage policy by not removing lettuce that appeared rotten and waterlogged and not labeling, dating, and monitoring refrigerated foods. This deficient practice has the potential to affect all 31 residents who consume food prepared in the facility's kitchen. On 11/19/2025 at 9:55 AM, the second refrigerator contained a single-serve garden salad on a transparent plate that was not covered. Multiple single-serve red gelatin portions were uncovered on a large tray with no date. Two individual transparent containers of ranch dressing were covered but had no date. V6 (Director of Dining Services) stated the gelatin was poured the day before on 11/18/2025 and that all foods placed in the refrigerator should be covered and labeled. [...]
- 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 follow Medication Administration Policy by not labelling a multi-dose jar of petroleum jelly with the open date. This failure affected 1 resident (R35) of 12 reviewed for medications.
December 13, 2024Standard inspection · 4 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 follow the food storage policy by not labeling food products with (cook or open) dates. This failure has the potential to affect 36 residents with oral diets.
- E
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 monitor the temperature of two of two medication refrigerators reviewed for medication storage. This failure has the potential to affect six of six Residents (R2, R3, R8, R14, R17, and R182) reviewed for medication storage in a sample of 14 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to adequately supervise a high fall risk resident for one of four residents (R26) reviewed for accidents in the sample of 14.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, and record review, the facility failed to administer immunizations to 3 of 5 residents (R15, R28 and R132) reviewed for immunization in a sample of 14 residents.
October 1, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to maintain resident safety during a mechanical lift transfer, failed to ensure the mechanical lift sling was correctly applied during transfers, and failed to use a two person assist during a mechanical lift transfer. This affected one resident (R1) of three residents reviewed for safety and mechanical lift transfer. This failure resulted in R1 sliding from mechanical lift sling, sustaining a 3cm (centimeter) laceration to the posterior scalp, being sent to the local hospital where 3 staples were required to close the laceration. Findings Include: Facility reported incident with date of occurrence of 8/27/24, reads in part: R1 had a witnessed fall during transfer from bed to wheelchair and was sent to ER (Emergency Room) for further evaluation. [...]
May 26, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to transfer a resident using a mechanical lift to ensure resident safety. This failure applied to one (R1) of three residents reviewed for resident injury and resulted in R1 sustaining a laceration to the leg while being transferred from wheelchair to bed; R1 required emergent hospital transfer and treatment with 12 sutures.
November 9, 2023Standard inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review facility failed to follow isolation procedures and usage of PPE (Personal Protective Equipment) for one (R5) resident. This failure has a potential to affect entire facility.
Fire safety inspections
41 fire safety citations on file: 11 on December 13, 2024, 8 on November 9, 2023, 22 on December 9, 2022.
Every fire safety citation41 citations
- F
Address subsistence needs for staff and patients.
E 15 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 13, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · December 13, 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 · December 13, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 13, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 9, 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 · November 9, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 9, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for sheltering.
E 22 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for medical documentation.
E 23 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · December 9, 2022 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 9, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 9, 2022 · Corrected (the home has a date of correction)
- F
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · December 9, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 9, 2022 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · December 9, 2022 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · December 9, 2022 · Corrected (the home has a date of correction)