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
1E
0F
Potential for minimal harm
0A
1B
0C
August 21, 2025Standard 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, it was determined that the facility failed to ensure sanitization of dishware in 1 of 1 kitchen observed.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to implement antibiotic use protocols that address unnecessary or inappropriate antibiotic use for 1 of 6 residents reviewed for antibiotic stewardship. (Resident identifiers is #38.)
August 14, 2024Standard inspection, Complaint inspection · 3 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to determine if self-administration is appropriate for a resident for 1 of 1 resident reviewed for respiratory care. (Resident Identifier #152).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview, record review, and policy review, it was determined that the facility failed to implement an ongoing systematic collection of surveillance data during a SARS-CoV-2 (COVID-19) outbreak from 7/7/24 to 7/25/24 and failed to ensure a system for identifying residents with COVID-19 through timely testing for 1 of 10 residents reviewed with respiratory symptoms (Resident Identifier is #99).
- B
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 policy review, it was determined that the facility failed to ensure food was stored at the proper temperature in 1 of 1 kitchenettes observed.
June 8, 2023Standard inspection · 3 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and medical record review it was determined that the facility failed to ensure the resident's right to formulated advance directives for 1 out of 13 residents reviewed for advance directives (Resident Identifier is #13).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined that the facility failed to follow physician's orders for 1 resident in a final sample of 13 residents (Resident Identifier is #34). Based on interview and record review determined that the facility failed to monitor a resident's weight for 1 resident reviewed in a final sample of 13 residents. (Resident Identifier is #32).
- 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 it was determined that the facility failed to ensure that medications were labeled with an opened date or use by date and expired medications were removed from use for 1 out of 2 medication carts and 1 out of 1 medication room observed (Resident Identifiers are #26 and #96).
Fire safety inspections
9 fire safety citations on file: 6 on August 21, 2025, 3 on August 14, 2024.
Every fire safety citation9 citations
- D
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 · August 21, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · August 21, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 21, 2025 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 21, 2025 · Corrected (the home has a date of correction)
- C
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
K 913 · August 21, 2025 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 21, 2025 · Corrected (the home has a date of correction)
- C
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 14, 2024 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · August 14, 2024 · Corrected (the home has a date of correction)
- B
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 14, 2024 · Corrected (the home has a date of correction)