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 15 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
2F
Potential for minimal harm
0A
0B
0C
February 26, 2026Standard inspection · 4 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 record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Observations revealed dented canned food items in the storage area, available for use. Additionally, observation revealed staff failed to practice hand hygiene during plating of meals.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview, record and facility policy review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective, person-centered care for 1 of 2 residents sampled for respiratory services (Resident (R) 76). Record review revealed the baseline care plan for R76 did not address the resident's CPAP (continuous positive air pressure) equipment use.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record and policy review the facility failed to ensure a resident with pressure ulcers received care consistent with professional standards of practice to promote healing for 1 of 2 residents (Resident (R) 84). Observations revealed an ordered pressure relieving device not in place as ordered.
- 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 facility policy review and records, the facility failed to ensure medication was securely stored for 1 (Resident #22) of 3 residents reviewed for accident hazards. The facility also failed to ensure medication carts were free from loose pills and debris, which affected 1 (West Wing Cart #1) of 3 medication carts observed.
January 23, 2025Standard inspection · 4 citations
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure physician orders were followed related to the administration of supplemental oxygen for 1 of 5 residents residents sampled for respiratory care (Resident (R)18) of a total resident sample of 24 residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, the insulin manufacturers' instructions for use, and facility policy review, the facility failed to ensure the medication error rate was less than 5%. This was evidenced by 2 medication errors out of 34 opportunities, resulting in a medication error rate of 5.88%, which affected 1 of 5 residents observed during medication pass (Resident (R) 63) out of a total resident sample of 24.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, record review, facility document and policy review, the facility failed to maintain a complete and accurate medical record for 1 of 5 residents sampled for unnecessary medications (Resident (R) 18) out of a total resident sample of 24. Observation revealed staff did not accurately document the correct dosage of insulin administered to R18.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, facility document and policy review, the facility failed to ensure it established and maintained 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 2 residents sampled for enhanced barrier precautions (Resident (R)298) out of a total resident sample of 24. Observation revealed staff failed to wear the proper personal protective equipment (PPE) when providing care to R298, who was on enhanced barrier precautions (EBP).
October 11, 2019Standard inspection · 7 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, record review and facility policy review it was determined the facility failed to store food in accordance with professional standards for food service safety as evidence by opened stored foods were undated and canned food labels were damaged/undated.
- E
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, record review, and facility policy it was determined the facility failed to ensure staff documented reconciliation of controlled medications at shift change. In addition, staff failed to immediately document removal of controlled medications; and, failed to keep medication carts locked and secured when unattended. Observations revealed staff failed to document removal of controlled medications, document verification of controlled substance medication counts at shift change, and insure medication carts were locked when unattended on three (3) of four (4) medication carts.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview it was determined the facility failed to ensure a discharge Minimum Data Set (MDS) was transmitted within fourteen (14) days for one (1) of eighteen (18) sampled resident's, Resident #2. The facility discharged Resident #2 to an acute care hospital on [DATE], with his/her return anticipated; however did not submit the MDS discharge data.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to code the annual Minimum Data Set (MDS) accurately for (1) resident of the eighteen (18) sampled residents. Resident #46 smoked cigarettes but the MDS revealed no tobacco use.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to follow physician's orders for one (1) of the eighteen (18) sampled residents, Resident #34. Resident #34 had orders for oxygen administered at four (4) liters (L). Observation revealed the oxygen concentrator set at three (3) L.
- 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, record review and review of policy it was determined the facility failed to ensure two (2) of two (2) refrigerated scheduled medication boxes were affixed to the medication refrigerators. Observations revealed the facility gray metal scheduled medication box in the East and [NAME] Unit were able to be completely removed from the refrigerators. In addition, the facility failed to ensure the pharmacy emergency scheduled medication kit was secured within an affixed box or area. Observation revealed the East Unit medication refrigerator contained a separate pharmacy medication container which contained scheduled medications and were closed with a green tug tie's and was not in a locked box or secured area. Interviews revealed the scheduled narcotic box was not audited by staff every shift.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and facility policy it was determined the facility failed to ensure staff performed hand hygiene during medication administration. Multiple observations revealed no hand hygiene performed by staff before or after medication administration and between residents.
Fire safety inspections
5 fire safety citations on file: 1 on January 23, 2025, 1 on June 21, 2024, 3 on October 11, 2019.
Every fire safety citation5 citations
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 23, 2025 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · June 21, 2024 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · October 11, 2019 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 11, 2019 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · October 11, 2019 · Corrected (the home has a date of correction)