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
3D
1E
0F
Potential for minimal harm
0A
0B
0C
December 31, 2025Standard inspection · 0 citations
November 7, 2024Standard inspection · 3 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review, and staff interviews the facility failed to perform daily wound care treatments on a sacral wound for 1 of 1 resident (Resident #4) observed for pressure ulcers.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, record review and staff interviews the facility failed to accurately document the completion of a wound treatment in the treatment administration record (TAR) for 1 of 1 residents (Resident #4) observed for pressure ulcers.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and staff interviews, facility staff failed to implement infection control policy and procedures when Nurse Aide (NA) #1 and NA #2 did not don Protective Equipment (PPE) to include a gown when providing high-contact resident care activities for Resident #49 who had an indwelling medical device. Resident #49 had a lower back indwelling pleural catheter which was used for draining fluid from the pleural space (fluid filled space that surrounds the lungs) to help with breathing. The deficient practice was identified for 2 of 2 staff members reviewed for infection control practices (NA #1 and NA #2).
September 14, 2023Standard inspection · 1 citation
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observations, record review, staff, Consultant Pharmacist, and Physician interviews the facility failed to protect a residents right to be free from misappropriation of a residents controlled medication (Oxycodone/Acetaminophen 5/325 milligrams (mg) , Hydrocodone/Acetaminophen 10/325 mg, Tramadol 50 mg, and Alprazolam 0.5 mg) which was prescribed by the physician for pain and anxiety. This resulted in a total of 42 doses of the medications that were not administered to 8 of 8 residents (Resident #51, #41, #2, #3,#4, #7, #8, #9) reviewed for misappropriation of medications.
Fire safety inspections
5 fire safety citations on file: 2 on November 7, 2024, 1 on September 14, 2023, 2 on May 26, 2022.
Every fire safety citation5 citations
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 7, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 7, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 14, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 26, 2022 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 26, 2022 · Corrected (the home has a date of correction)