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
7D
4E
2F
Potential for minimal harm
0A
0B
0C
September 5, 2025Standard inspection · 4 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was administered timely in accordance with the physician order for one of 12 sampled residents (Resident 46). This failure had the potential for adverse health outcomes related to incorrect medication administration time.
- 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 prevent the spread of infections during kitchen observation when a staff member did not perform hand hygiene after touching a contaminated item. This failure had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the garbage dumpster (a movable waste container) lid was kept closed. This failure had the potential to attract insects, rodents, and other pests to the facility.
- 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 interview and record review, the facility failed to identify appropriate interventions for two of 12 residents (Resident 4 and 38):1. Resident 4's dysphagia (difficulty in swallowing foods or liquid) care plan had no interventions; and2. Resident 38's wound care plan did not indicate wound care interventions. This failure had the potential to compromise the facility's ability to implement interventions.
May 3, 2024Standard inspection · 5 citations
- F
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails ((adjustable rigid bars attached to the side of a bed) for 25 of 25 sampled residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170) when: 1. The facility failed to assess for the risk of entrapment from side rails prior to use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 2. [...]
- 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 ensure food items were labeled properly and expired food were not stored in the kitchen and accessible to be used in preparing foods for 23 of 25 residents. This practice had the potential to result in the residents ingesting expired food, which can result in foodborne illnesses.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC, informs beneficiaries on how to file an appeal before their insurance coverage ends) timely for two of three sampled residents (Resident 80 and 81). This deficient practice had the potential to result in residents not being able to exercise their right to file an appeal.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to ensure the plan of care for one of 25 sampled residents (Resident 1) was individualized and revised to reflect the resident's current care needs and interventions. This failure had the potential to result in not meeting the residents' needs.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to ensure two of 25 residents (Residents 74 and 79)'s foot boards of their beds were properly locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents.
May 5, 2023Standard 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 failed to ensure sanitary conditions were maintained for one of three ice machines when an ice machine had a brown-yellow substance in an interior part of the machine was exposed to ice. This failure had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins). The ice machine was used to provide ice for the residents.
- 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 and interview, the facility failed to ensure proper storage of medical supplies when expired hypodermic safety needles (medical tool, designed for safe one-time use, to inject or extract fluids from the body via a thin hollow tube with a sharp tip), were stored in an active use area inside the medication storage room. This deficient practice had the potential for use of expired medical tools on residents.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was disposed of properly in the outside garbage area when a dumpster lid was left open, garbage and linen bags were left outside the dumpsters, and garbage was on the ground. This failure had the potential to attract vermin (pests or animals that spread diseases).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control strategies when a certified nursing assistant with long fingernails took care of residents. This failure resulted in increased risk of disease transmission to residents via long fingernails, which provide more area(s) where microbes may harbor compared to short fingernails.
Fire safety inspections
6 fire safety citations on file: 1 on September 5, 2025, 3 on May 3, 2024, 2 on May 5, 2023.
Every fire safety citation6 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 5, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 3, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 3, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 3, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · May 5, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 5, 2023 · Corrected (the home has a date of correction)