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
6D
2E
0F
Potential for minimal harm
0A
0B
0C
March 31, 2026Standard inspection · 0 citations · risk-based survey (a shorter visit CMS gives only to higher performing homes)
May 15, 2025Standard 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 observation, interview and record review, the facility did not ensure proper food handling practices related to thawing raw meat were followed to prevent the outbreak of foodborne illness for 26 of 82 residents. Facility did not use proper thawing method for frozen pork chops. Policy and procedure titled Food Preparation and Service last revised in August of 2014 reads in part, Submerging the item in cold running water. Guidelines from Agriculture, Trade, and Consumer Protection Subpart 3-501.13 last registered in November 2024, reads in part, Completely submerged under running water .With sufficient water velocity to agitate and float off loose particles in an overflow. The FDA Food Code states the following: 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water: [...]
- 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 observation, interview and record review, the facility did not implement comprehensive person-centered care plan approaches for 1 of 1 sampled resident (R), (R46) by ensuring fall intervention approaches were in place to meet a resident's medical, nursing, and psychosocial needs which are identified. This is evidenced by: The facility policy, titled Falls and Fall Risk, managing policy statement states, Based on previous evaluations and current data, the staff will identify interventions related to the residents from falling and to try to minimize complications from falling. 6. Staff will identify and implement relevant interventions .to try to minimize serious consequences or falling. R46 was admitted to the facility on [DATE] and has diagnoses of unspecified dementia, mild, with psychotic disturbance with delirium and adult failure to thrive. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 residents (R), (R20, R53) included in the medication pass task, which resulted in an error rate of 6.9%. -R5's prescribed topical medication was used for R20. -R53's lidocaine patch was not removed after 12 hours, as ordered.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (R) reviewed (R57). - R57's Foley catheter collection bag was observed placed above bladder level allowing backflow which can contribute to infections. On 05/13/25, half of R57's Foley catheter bag was lying on the floor uncovered. This is evidenced by: The facility policy titled, Catheter Care, Urinary indicates the following, . 4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 11. Be sure the catheter tubing and drainage bag are kept off the floor. [...]
April 3, 2024Standard 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 observation, interview and record review, the facility did not ensure proper hand hygiene with food handling in accordance with professional standards for food service safety. This has the potential to affect all 24 residents in the south dining room out of 64 residents residing in the facility. The dietary aide touched multiple contaminated surfaces with gloved hands, did not remove her gloves or wash her hands, and used her gloved hands to serve garlic bread on resident plates.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 5 residents (R) reviewed (R36) who is unable to carry out activities of daily living independently, receives the necessary services to maintain good nutrition, repopositioning with personal hygiene and oral hygiene. This is evidenced by: R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. Surveyor reviewed the most recent Minimum Data Set (MDS) assessment completed for R36, which was a quarterly assessment with an assessment reference date of 3/7/24. [...]
- 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 observations, record review, staff interview and policy review, the facility failed to ensure 1 of 3 residents (R) R36 reviewed for limited mobility, received restorative services as needed to address limited mobility, to maintain or improve mobility for the goal to reach the maximum practicable independence. R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. Surveyor reviewed the most recent Minimum Data Set (MDS) assessment completed for R36, which was a quarterly assessment with an assessment reference date of 3/7/24. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure hand hygiene was conducted appropriately for 1 of 1 care observations (R36). This is evidenced by: The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items. C. Decontaminate hands before having direct contact with patients . F. Decontaminate hands after contact with a patient's intact skin. G. [...]
Fire safety inspections
11 fire safety citations on file: 1 on March 31, 2026, 7 on May 15, 2025, 3 on April 3, 2024.
Every fire safety citation11 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 31, 2026 · 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 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 15, 2025 · Corrected (the home has a date of correction)
- E
Have power receptacles that are properly grounded.
K 912 · May 15, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 15, 2025 · 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 3, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 3, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · April 3, 2024 · Corrected (the home has a date of correction)