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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
1E
1F
Potential for minimal harm
0A
1B
1C
April 8, 2026Standard inspection · 0 citations
April 24, 2025Standard inspection · 4 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and review of the facility's Certified Nursing Assistant (CNA) job description and policy, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Observation and interview revealed an average call light response time of 15 - 20 minutes for three of 50 sampled residents, (Resident (R)15, R42, and R196).
- 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, facility policy review, and review of manufacturer's instructions, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or labeled with currently accepted professional principles, including the expiration date when applicable. Observation of a medication storage room revealed two Tuberculin vials stored in the refrigerator were opened but not labeled with a date as to calculate its discard date. Observation also revealed two vials of Tuberculin dated with a date that was beyond the 30 day manufacturer's required discard date. Additionally, observation revealed 60 COVID-19 test kits stored beyond the manufacturer's expiration date.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 sampled residents, (Resident (R)10). During observation on 04/24/2025 at 3:33 PM, Licensed Practical Nurse (LPN) 5 was observed to blow her nose; however, failed to perform hand hygiene after doing that. The LPN was then observed to touch R10's packaged medications and administer them to the resident.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure survey results were posted in a place readily accessible, where individuals wishing to examine the survey results did not have to ask to see them. The facility's failure affected 8 residents who attended the resident council meeting (Resident (R)4, R11, R12, R24, R31, R32, R36, and R38) and had the potential to affect all residents residing in the facility, as well as family/representatives, and visitors of the facility who had the right to review the facility's survey history. Observation revealed the facility's survey binder was not located in a readily accessible place and interview revealed the binder had been stored in the Administrator's office.
February 14, 2020Standard inspection · 8 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 observation, interview, and review of the facility policy it was determined the facility failed to ensure infection control practices were maintained in the kitchen. On 02/11/2020, during the lunch and supper tray line, observations revealed a kitchen employee left the tray line and returned without changing gloves and performing hand hygiene. Further observation revealed a kitchen employee plated food and on three (3) occasions returned the food to the steam table pan.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure a homelike environment for one (1) of eighteen (18) sampled residents (Resident #44). A chair was observed in Resident #44's room that was torn with the inside padding protruding out of the upholstery.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents (Resident #27) received respiratory care consistent with professional standards of practice. Resident #27 was observed to have their oxygen concentrator set to deliver three (3) liters per minute (LPM) during observation on 02/11/2020 and 02/13/2020. Review of the physician order revealed the resident's oxygen was ordered for two (2) LPM. Further observation on 02/13/2020 revealed the resident's oxygen tubing, attached to the resident's portable oxygen cylinder, was dated 12/14/2019.
- 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 review of the facility policy it was determined the facility failed to ensure proper storage and labeling of medications on two (2) of four (4) medication carts. Observation on 02/13/2020 revealed an opened, undated Lantus insulin pen on Medication Cart 2 and an opened and undated Basaglar insulin pen on a treatment cart. Both medications were available for use.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to ensure resident food preferences were honored for one (1) of eighteen (18) sampled residents (Resident #99) related to food dislikes and food/drink requests.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure accurate record documentation for one (1) of eighteen (18) sampled residents (Resident #7) related to the application of splints. Facility staff had documented that bilateral hand splints were applied to Resident #7's hands daily; however, staff interviews revealed the splints were not applied as documented. In addition, the order to place Resident #7's hand splints on hold was not transcribed to the Medication Administration Record (MAR).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of infections for one (1) of eighteen (18) sampled residents (Resident #17). Observation on 02/11/2020 revealed while assisting Resident #17 with dinner, facility staff directly touched the resident's food with ungloved hands.
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and review of the facility policy it was determined the facility failed to ensure the posting of daily staffing included all required elements. Observation on 02/11/2020, 02/12/2020, and 02/13/2020 revealed the posted daily staffing did not include the daily census or hours worked.
Fire safety inspections
24 fire safety citations on file: 7 on April 8, 2026, 14 on April 24, 2025, 3 on February 14, 2020.
Every fire safety citation24 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 8, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 8, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 8, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 8, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 8, 2026 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 8, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 8, 2026 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 24, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 24, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 24, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · 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
Install corridor and hallway doors that block smoke.
K 363 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · 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)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 14, 2020 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · February 14, 2020 · Corrected (the home has a date of correction)
- D
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · February 14, 2020 · Corrected (the home has a date of correction)