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
12D
1E
0F
Potential for minimal harm
0A
0B
0C
June 4, 2026Standard inspection · 3 citations
- E
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, record review and interviews the facility failed to properly store medications in two out of two medication rooms as evidenced by an expired emergency kit in the North medication room and a thermometer reading of 52 degrees Fahrenheit in the South medication room.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility did not consistently store, prepare, distribute, and serve food in a sanitary manner within the kitchen and nourishment rooms. This was evidenced by the presence of undated, unlabeled, and expired food items and dietary staff not wearing required hair restraints, including beard guards, during food preparation. There were 117 residents residing in the facility at the time of the survey
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, record review, and interview, the facility failed to demonstrate or implement effective plan of actions to correct identified quality deficiency in the problem area related to repeated deficient practice for F761- Label/Store Drugs and Biologicals as evidenced by an expired emergency kit and thermometer reading 52 degrees Fahrenheit found in medication rooms during observations on a recertification survey ending [DATE]. There were 117 residents in the facility at the time of survey. Record review of the facility's survey history revealed, during a recertification conducted on [DATE], through [DATE], the facility was cited F761- Label/Store Drugs and Biologicals as the facility failed to ensure proper storage of medications. Review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan undated states: [...]
November 21, 2024Standard inspection · 5 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review and interviews the facility failed to implement quality of care and service related to a trial for removal of restraints for one resident (Resident #47) out of eight sampled residents as evidenced by; a trial removal of restraints was initiated without a physician's order. There were 110 residents residing in the facility at the time of the recertification survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and interviews the facility failed to provide a safe environment for one resident (Resident #46) out of eight residents sampled as evidenced by an observation of four shaving razors on Resident#46 nightstand.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and interviews, the facility failed to administer oxygen as prescribed for one resident (Resident #83) out of eight sampled residents, as evidenced by observations of Resident #83 without oxygen in progress. The findings Included: During an Observation on 11/19/24 at 9:31 AM Resident #83 was lying in bed with eyes closed; the there was a nasal cannula on top of a pillow next to the resident and the oxygen concentrator at bedside was running at 2 liters per minute (L/min). On 11/19/24 at 9:31 AM am an interview was held with Resident#83's daughter and who revealed the resident#83 doesn't require continuous oxygen. On 11/20/24 at 2:48 PM Resident #83 observed in the dining room area participating in activities with no oxygen in progress. [...]
- 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 observations, record review and interviews the facility failed to properly store medications for four residents (Resident #53, Resident #313, Resident #314, and Resident #315) and one medication cart out of three sampled medication carts as evidenced by pills, eye drops, ointments and nasal sprays at the bedside of residents and an expired Moxifloxacin eye drop on the North 2100 medication cart. There were 110 residents residing in the facility at the time of recertification survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interviews, the facility failed to follow infection control protocol in the laundry room. As evidenced by observation of lint traps that were not cleaned, the lint log indicated lint traps were cleaned every two hours and was signed daily at 5:00 AM although laundry staff start at 6:00 AM.
August 9, 2023Standard inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to treat one resident (Resident #18) out of one resident with dignity and respect who was observed during dining, as evidenced by staff member standing while feeding the resident. This deficient practice had a potential to affect the health and wellbeing of all 39 residents who are dependent with eating.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, the facility failed to electronically transmit the Quarterly Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) System within 14 days after completing the resident's assessment for one out of one sampled resident (Resident # 43 ) reviewed for timely submissions of resident assessments.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pharmaceutical procedures for Residents (#44, #295) as evidenced by medications being left on the overbed table for Resident #44, Omission of one (1) medication for Resident #295 during the medication administration observation and two (2) loose pills found in the medication drawer of North Station 2100 Hall cart. Three residents were observed for medication administration totaling 29 opportunities. Three medication carts and One medication storage room was observed. There were 116 residents residing in the facility at the time of the survey.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was free of a significant medication error, as evidenced by Resident #295 Extended Release (ER) blood pressure medication being crushed by the nurse to be administered to the resident during the medication administration observation. Three residents were observed during medication administration totaling 29 opportunities. There were 116 residents residing in the facility at the time of the survey.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review and interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F640 Encoding/Transmitting Resident Assessments and F755 Pharmacy Services/Procedures/Pharmacist/Records. This practice has the potential to increase the risk of negative resident outcomes and affect all 116 residents residing in the facility at the time of this survey.
Fire safety inspections
4 fire safety citations on file: 1 on November 21, 2024, 1 on April 4, 2024, 2 on August 9, 2023.
Every fire safety citation4 citations
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 21, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 9, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 9, 2023 · Corrected (the home has a date of correction)