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 4 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
1E
1F
Potential for minimal harm
0A
0B
0C
April 26, 2026Standard inspection · 0 citations
April 24, 2025Standard inspection, Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policies Handwashing/Hand Hygiene, and Medication Administration-General Guidelines, the facility failed to perform proper hand hygiene practices while observing two out of two Licensed Practical Nurses (LPN) (LPN AA and LPN BB) during medication administration. This deficient practices had the potential to increase the risk of infection transmission and compromise the health and safety of residents. The facility census was 55 residents.
April 16, 2023Standard inspection · 3 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Pot and Pan Washing and Sanitation, Dishwashing, Food storage and Inventory, Food temperatures, and Personal Hygiene, the facility failed to ensure pans were stored dry to prevent bacterial growth; failed to store food items off the floor in the dry storage area and walk-in refrigerator; failed to ensure resident nourishment refrigerator food items were properly labeled and dated; failed to ensure all food items served on the steam table were held above 135 degrees Fahrenheit; and failed to ensure male dietary staff completely covered facial hair. These deficient practices affected all 39 residents consuming an oral diet.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review, staff interview, and review of the facility's policies titled, Automatic Stop Orders, and Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for four of four residents (R) (R#13, R#9, R#14, R#21) reviewed for unnecessary medications. This failure had the potential for medication interaction, adverse reactions, respiratory depression, falls, constipation, and increased anxiety.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure the filter on an oxygen concentrator for one of four residents (R) (R#20) receiving oxygen therapy was changed per physician's order. This failure had the potential to compromise R#20's access to the required level of oxygen.
Fire safety inspections
13 fire safety citations on file: 5 on April 26, 2026, 4 on April 24, 2025, 4 on April 16, 2023.
Every fire safety citation13 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 · April 26, 2026 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · April 26, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 26, 2026 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · April 26, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 26, 2026 · Corrected (the home has a date of correction)
- F
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 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 16, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 16, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 16, 2023 · Corrected (the home has a date of correction)