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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
2E
1F
Potential for minimal harm
0A
0B
0C
May 11, 2026Complaint inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review, observation, record review, and family and staff interviews, the facility failed to ensure a resident who was dependent on staff for transfers received timely assistance with being transferred back to bed. This affected one (#8) of one resident reviewed for activities of daily living. The facility census was 95.
- 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, staff interviews and record review, the facility failed to ensure medications were not left at a resident bedside unattended. This affected one (#36) of one resident observed for environmental safety. The facility census was 95.
June 11, 2025Complaint inspection · 1 citation
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, menu spreadsheet review, portion control chart review, diet order review, and interview, the facility failed to ensure the menu was followed for nutritional adequacy. This affected four residents (Resident #61, #65, #71 and #33) and had the potential to affect all 54 residents (Resident #1, #2, #3, #4, #6, #8, #9, #10, #11, #12, #15, #17, #20, #22, #23, #25, #29, #31, #32, #33, #35, #36, #37, #40, #41, #42, #43, #45, #46, #47, #48, #49, #50, #52, #55, #56, #57, #60, #61, #62, #63, #65, #66, #69, #71, #72, #74, #76, #79, #80, #81, #83, #84, and #89) who were served food from the 2B kitchenette/dining. The census was 90.
April 29, 2025Complaint inspection · 1 citation
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on resident, family, and staff interview, observation, policy review, and record review, the facility failed to ensure Resident #40's bathing preferences were honored. This affected one (Resident #40) of one resident reviewed for bathing. The facility census was 85.
December 21, 2024Complaint inspection · 2 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Resident #10's narcotic pain medications were not misappropriated. This finding affected one (Resident #10) of three residents reviewed for medication administration.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to report an allegation of misappropriation of Resident #10's oxycodone narcotic pain medications to the State Survey Agency as required. This finding affected one (Resident #10) of three residents reviewed for misappropriation.
May 22, 2024Standard inspection · 3 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure a comprehensive water management plan which had the potential to affect all residents; ensure staff were alerted Resident #5, #19, and #53 were on Enhanced Barrier Precautions (EBP), and failed to ensure appropriate infection control practices were maintained during medication administration affecting Residents #16 and #72. The facility census was 88.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview, record review and policy review the facility failed to ensure Resident #9 was offered and received education regarding the influenza and pneumonia vaccines. This affected one of five residents reviewed for immunizations (Residents #26, #32, #27, #79, and #9). The facility census was 88.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview, record review and policy review the facility failed to ensure Resident #9 was offered and received education on the Covid-19 vaccine. This affected one of five residents reviewed for immunizations (Residents #26, #32, #27, #79, and #9). The facility census was 88.
April 21, 2022Standard inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident #322) received scheduled doses of anticoagulant (blood thinner) medication due to unavailability of the medication. This affected one (Resident #322) out of five (Resident #11, #12, #63, #69 #322) residents reviewed for unnecessary meds. The census was 79.
April 25, 2019Standard inspection · 3 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, staff interview, and facility policy revealed the facility failed to maintain appropriate refrigerator temperatures and date opened containers in the activity room refrigerators. This had the potential to affect 30 Residents who ate food stored in the activity room refrigerator. (Resident #63, #4, #76, #40, #16, #39, #48, #10, #67, #72, #187, #22, #74, #24, #18, #11, #20, #8, #79, #25, #44, #29, #41, #21, #19, #6, #23, #27, #58, #31). The facility census was 88.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide evidence of written notification to the resident and/or representative regarding beneficiary notices. This affected two residents (Residents #40 and #87) out of three residents (Residents #40, #87, and #88) reviewed for beneficiary notices. The facility census was 88.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure thorough catheter care was provided for Resident #51, one of one resident reviewed for urinary catheter. The facility identified four residents with indwelling urinary catheters. The facility census was 88.
Fire safety inspections
31 fire safety citations on file: 8 on May 22, 2024, 7 on April 21, 2022, 16 on April 25, 2019.
Every fire safety citation31 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 22, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 22, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 21, 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 · April 21, 2022 · Corrected (the home has a date of correction)
- E
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 · April 21, 2022 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 21, 2022 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 21, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 21, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 21, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 25, 2019 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · April 25, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 25, 2019 · 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 · April 25, 2019 · 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 · April 25, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 25, 2019 · 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 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · April 25, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 25, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · April 25, 2019 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · April 25, 2019 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · April 25, 2019 · deficient, provider has