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
6D
2E
6F
Potential for minimal harm
0A
0B
1C
April 22, 2026Standard inspection · 8 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide eight consecutive hours of Registered Nurse (RN) staff daily for the residents of the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 11 with a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer. The facility further failed to ensure adequate hand hygiene before medication administration for R11 and R2.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a written baseline care plan to Resident (R) 1, R2, 11, and R4.
- 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, interview, and record review, the facility failed to store and label biologicals adequately when staff failed to date an insulin (medications used to treat high blood glucose levels) pen when opened.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident (R) 1 received the opportunity to participate in the care planning process when staff failed to invite R1, or their responsible party to care plan meetings.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interviews, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for Resident (R) 10 and R3.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately assess Resident (R) 11's present-on -admission pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at the time of admission and failed to ensure wound treatment orders were obtained and treatments provided.
- C
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on observation, interview and record review, the facility failed to electronically submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) related to weekend staffing.
June 12, 2024Standard 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 wroteThe facility reported a census of four residents. Based on observation, interview, and record review, the facility failed to serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. This deficient practice had the potential to negatively affect all residents in the facility.
- F
Dispose of garbage and refuse properly.
Inspectors wroteThe facility reported a census of four residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests.
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteThe facility reported a census of four residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 59 dates between 01/01/23 and 12/31/23.
- F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteThe facility reported a census of four residents. Based on interview and record review, the facility failed to ensure five of five Certified Nurse Aides (CNAs) reviewed had the required in-service education which included the abuse, neglect and exploitation (ANE) and one CNA which also lacked dementia management training. This deficient practice placed the residents at risk for inadequate care.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteThe facility reported a census of four residents with four residents sampled. Based on interview and record review, the facility failed to accurately complete a comprehensive assessment on the Minimum Data Set, for resident (R)7 within the time frame of 14 calendar days.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of four residents. The sample included four residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to hand hygiene by lack of hand hygiene during R7's peripherally inserted central catheter (PICC-a form of access directly into the bloodstream via a vein that can be used for a prolonged period of time) to prevent the spread of infection.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility reported a census of four residents with four residents sampled. Based on interview and record review, the facility failed to provide requested vaccination to one of the residents. Resident (R) 6 requested the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]).
June 8, 2022Standard inspection · 0 citations
Fire safety inspections
20 fire safety citations on file: 10 on April 22, 2026, 8 on June 12, 2024, 2 on June 8, 2022.
Every fire safety citation20 citations
- F
Address subsistence needs for staff and patients.
E 15 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 22, 2026 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · April 22, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 22, 2026 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · June 12, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 12, 2024 · Corrected (the home has a date of correction)
- E
List the names and contact information of those in the facility.
E 30 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 12, 2024 · Corrected (the home has a date of correction)
- F
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · June 8, 2022 · Waiver
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 8, 2022 · Corrected (the home has a date of correction)