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 9 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
0E
2F
Potential for minimal harm
0A
0B
0C
December 4, 2025Standard inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Resident 4's Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) protocol were not followed in accordance with facility's policy and procedure (P&P). 2. One glucose monitoring (a device used to measure the amount of sugar (glucose) in the blood) device was found visibly soiled with dried white substance while docked (recharged) at the nurse's station. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 7 medically compromised residents and staff in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff provided treatment appropriately for one of seven sampled resident (Resident 18) when the nursing staff did not check Resident 18's blood glucose (sugar) daily as ordered. This failure resulted in Resident 18 inadequately monitored for blood sugar, which had the potential to cause uncontrolled blood sugar and negatively affect Resident 18's health and safety.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post facility name, and the total number and the actual hours worked per shift for licensed and unlicensed staff daily. This failure resulted in residents, family, and staff being unable to see if the unit is staffed appropriately.
- 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 record review, the facility failed to ensure drugs and biologicals were properly labeled for one of three sampled residents (Resident 7) when the gastrostomy tube (G-Tube-a soft tube placed through the skin directly into the stomach) formula bottle (a bottle premixed medical nutrition formula used for tube feeding to provide calories, proteins and nutrients when a resident cannot eat by mouth is given by the stomach) was not labeled with nurse initials and the water flush bag (a water bag used to deliver scheduled water flushes though the feeding tube to maintain hydration and keep the tube clear) was not labeled with the prescribed rate as required. [...]
- D
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review, the facility failed to ensure the successful electronic submission of complete and accurate direct care staffing information was transmitted to Centers for Medicare and Medicaid Service (CMS) for two quarters (May 13, 2025, and August 14, 2025). This failure resulted in the facility not being monitored for any potential staffing issues.
November 8, 2024Standard inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that enhances quality of life for two of five sampled residents (Residents 55 and 56) when lunch was served in a plastic bag with disposable plastic container and utensils and no placemat, tray or plate were provided. This failure resulted in Residents 55 and 56 not having a place to set their food when eating and having to place some items on the table when preparing their meal to eat which had the potential to negatively impact the residents' mental and psycho-social well-being.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was completed and submitted to CMS in accordance with federal submission timeframes, for one of six reviewed for resident assessment (Resident 1). This failure resulted in inadequate monitoring of progress or decline for Resident 1 and the lack of resident specific information to CMS for payment and quality measure monitoring.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow policy and procedure (P&P) for four of five residents when: 1. Staff failed to perform hand hygiene during medication administration and having direct contact with three residents (Resident 55, 56, and 106). 2. Intravenous (IV-into the vein) tubing was not used according to standards of practice for one resident (Resident 57) when the facilities policy and procedure (P&P) for IV therapy was not updated. These failures had the potential to place patients at a greater risk for spreading of infection from cross-contamination (the transfer of harmful bacteria) causing a preventable bloodstream infection, and negatively impact residents' health and safety.
November 16, 2023Standard inspection · 1 citation
- 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 maintain a sanitary kitchen in accordance with professional standards for food safety when: 1. In the kitchen entrance, there was no available hair restraints (such as hair nets and beard restraints) for kitchen staff and visitors to use. 2. Three kitchen staff, who had beards, were not wearing beard restraints while working inside the kitchen. These failures had the potential to cause foodborne illnesses to 8 medically compromised residents who receive food served by the kitchen.
Fire safety inspections
11 fire safety citations on file: 3 on December 4, 2025, 5 on November 8, 2024, 3 on November 16, 2023.
Every fire safety citation11 citations
- F
Have power receptacles that are properly grounded.
K 912 · December 4, 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 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 4, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 8, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · November 8, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 8, 2024 · Corrected (the home has a date of correction)
- C
Have elevators that firefighters can control in the event of a fire.
K 531 · November 8, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 8, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 16, 2023 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · November 16, 2023 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · November 16, 2023 · Corrected (the home has a date of correction)