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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
2E
0F
Potential for minimal harm
0A
0B
0C
April 11, 2025Standard inspection · 6 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 policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 4 of 19 staff members (Certified Nursing Assistant (CNA) F, G, H and Activity Assistant E) failed to perform hand hygiene and handled food with barehand during dining observations, and when 1 of 2 staff (Dietary [NAME] I) failed to perform proper hand hygiene when preparing meal trays. The facility had a census of 166 with 166 of those residents receiving a tray from the kitchen.
- 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 policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 4 of 33 sampled residents (Resident #21, #71, #77 and #108) reviewed for Advance Directives.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 23 of 23 CNAs (CNA G, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, and EE) employed for a full year received at least 12 hours of in-service training.
- 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 policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 4 staff members (Registered Nurse (RN) II) left the medication unattended and out of sight at the bedside in Resident #10's room.
- D
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on Quarterly Payroll Based Journal (PBJ), staffing time sheets, and interview the facility failed to submit accurate staffing data for Quarter 2, Quarter 3, and Quarter 4/2024.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, medical record review, observation, and interviews, the facility failed to ensure infection control practices to prevent the spread of infection were used when 1 of 5 (Registered Nurse (RN II) nurses failed to perform hand hygiene during medication administration and Certified Nursing Assistant (CNA) LL was not following Enhance Barrier Precautions (EBP)s while providing care for Resident #311.
October 23, 2019Standard inspection · 2 citations
- K
Provide and implement an infection prevention and control program.
Inspectors wroteBased on the glucometer manufacturer guideline, medical record review, observation and interview, the facility failed to follow standard precautions during the performance of routine fingerstick blood glucose testing resulting in potential exposure of residents who required blood glucose testing to the spread of bloodborne infections in the facility for 3 (#26, #99 and #117) of 32 diabetic residents. The Administrator was informed of the Immediate Jeopardy (IJ) on 10/22/19 at 1:15 PM in the Director of Nursing's office. F-880 was cited at a scope and severity of K. An extended survey was effective from 10/22/19 to 10/23/19. The Immediate Jeopardy was effective on 10/22/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy was received on 10/23/19 at 11:34 AM and corrective actions were validated onsite by the surveyors on 10/23/19.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide food and beverages at a palatable and appetizing temperature for 1 tray delivery cart, containing 22 resident meal trays, of 3 tray delivery carts delivered to the 1st floor.
July 11, 2018Standard inspection · 3 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, review of a facility reported incident, medical record review, observation, review of a facility surveillance video, and interview, the facility failed to protect 2 (#316, #26 ) of 5 residents reviewed for physical abuse. The abuse resulted in actual Harm to Resident #316.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working on the tray line without wearing a beard net on 1 of 3 observations.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, medical record review, observation and interview, the facility failed to change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed.
Fire safety inspections
12 fire safety citations on file: 6 on April 11, 2025, 6 on July 11, 2018.
Every fire safety citation12 citations
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · July 11, 2018 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · July 11, 2018 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 11, 2018 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 11, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 11, 2018 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 11, 2018 · Corrected (the home has a date of correction)