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 10 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
0B
0C
April 15, 2026Standard inspection · 0 citations
February 6, 2025Standard inspection · 4 citations
- F
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 accurately report to the Centers for Medicare and Medicaid Services (CMS) the direct care hours based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for the fourth quarter of fiscal year 2024 ([DATE] - [DATE]) for one (1) of (1) quarters reviewed.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to revise a comprehensive care plan for Diabetes Mellitus to include interventions related to a continuous glucose monitoring (CGM) device for one (1) of (20) care plans reviewed. Resident #49.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow professional standards for blood glucose monitoring by not ensuring standardized documentation, physician orders for accu-check monitoring, staff training on continuous glucose monitoring (CGM) use and maintenance, and clear protocols on when to use the CGM versus a traditional glucometer for one (1) of twenty (20) sampled residents, Resident #49.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interviews, record review, and ServSafe Coursebook review, the facility failed to label and date food stored in the refrigerator and freezer and failed to dispose of spoiled foods for one (1) of four (4) days of kitchen observations.
June 22, 2023Standard inspection · 6 citations
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, staff interview, resident interview, and record review, the facility failed to ensure an effective pest control program was maintained as evidenced by multiple flies observed throughout the facility for three (3) of four (4) days of survey.
- 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 record review, facility policy review, and staff interview, the facility failed to ensure the residents that do not have an Advanced Directive (AD) received information or assistance in formulating an AD for four (4) of 24 resident records reviewed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, staff interviews and facility policy review, the facility failed to implement a care plan regarding physician notification, dialysis communication and failed to provide thicken liquids for two (2) of 24 care plans reviewed Resident #6 and Resident #28 Findings Include: Record review of facility policy titled Comprehensive Care Plans, dated 07/29/19, stated, The village care plan team, in coordination with the resident, the resident's family members or the resident's representative develops and maintains a comprehensive care plan for each resident which identifies the highest level of functioning the resident is expected to obtain. Resident #6 Record review of the resident care plan with problem onset date of 10/28/19 revealed a care plan for Elder lives with ESRD (End Stage Renal Disease) and requires hemodialysis. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, record review, staff interviews, and facility policy reviews, the facility failed to provide hydration during a meal to a resident who was a choking risk, for one (1) of three (3) residents reviewed for nutrition Resident #28. Findings Include: Record review on facility letterhead dated 06/20/23 and signed by the Administrator stated, Our home does not currently have policies regarding checking tray accuracy, preparing trays, and communication with the Registered Dietician (RD). On 06/19/23 at 12:10 PM an observation was made of Resident #28 laying in her bed, eyes open, soft speech, able to shake head yes/no to questions appropriately that was asked of her. Certified Nursing Assistant (CNA) #3 entered the room and placed the residents meal tray on the bedside table and moved the bedside table over to the resident and began meal set up. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, record review, staff interviews and facility policy review, the facility failed to maintain communication with the physician and maintain dialysis communication sheets for a resident who receives dialysis services for seven (7) of 34 days that Resident #6 attended or refused dialysis.
- 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, staff interviews, record reviews and facility policy review, the facility failed to store medications in a locked medication cart for one (1) of three (3) medication carts reviewed. Medication Cart on Back Hall Findings Include: Record review of the facility policy titled Medication Storage, dated 05/31/23, revealed .Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). b. Only authorized personnel will have access to the keys to locked compartments . On 06/19/23 at 12:15 PM, an observation was made of medications sitting on the bedside table of Resident #6. The resident was out to dialysis and not in her room. Observed medications of Refresh eye drops, Advair Disk inhaler and Astepro nasal spray. [...]
Fire safety inspections
2 fire safety citations on file: 1 on February 6, 2025, 1 on June 22, 2023.
Every fire safety citation2 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 6, 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 · June 22, 2023 · Corrected (the home has a date of correction)