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
5D
0E
4F
Potential for minimal harm
0A
0B
0C
January 22, 2026Standard inspection, Complaint inspection · 2 citations
- 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 review of the facility policy, observations, and interviews, the facility failed to ensure medications and biologicals remained sterile in 1 of 1 treatment carts reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies, record review, observations and interviews, the facility failed to ensure proper personal protective equipment (PPE) was used for Resident (R)2 during a dressing change. In addition, the facility failed to follow proper procedures related to dressing changes for 1 of 1 resident reviewed.
October 10, 2024Standard inspection · 3 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 facility policy the facility failed to ensure that opened food items were properly labeled and stored, 2 of 2 kitchens reviewed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review, and facility policy, the facility failed to ensure Resident (R)4 had adequate supervision to prevent a fall. 1 of 3 reviewed for accident/hazards.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to clarify one of one sampled resident (Resident (R1) physician's orders regarding the correct CPAP Support Therapy mode and settings. Findings Include: A review of the facility policy titled CPAP/ BiPAP Support, with a complete revision date of March 2015 states - Preparation 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP, and EPAP) for the machine. 4. Review and follow the manufacturer's instructions for CPAP machine setup and oxygen delivery. Steps in the procedure 8. Set mode, CPAP, IPAP, and EPAP settings on the machine, as prescribed. Documentation- Document the following in the resident's medical record: 3. [...]
May 18, 2023Standard inspection · 4 citations
- F
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 review of the facility policy titled, Storage of Medications, and Controlled Substances, observations, and interviews, the facility failed to ensure a small metal box containing narcotics was permanently affixed in one of one medication refrigerators located in one of one medication storage rooms. The facility further failed to ensure discontinued narcotics were secured and double locked, while awaiting destruction. The facility additionally failed to ensure 4 insulin pens, in use, were dated with an open date and expiration date once opened in one of two medication carts.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food was stored and labeled properly in the dry goods storage, walk-in fridge, and walk- in freezer to prevent the spread of foodborne illnesses. The facility also failed to ensure the ice machine was properly sanitized and/or cleaned.
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of facility policy, interview and record review, the facility failed to track and trend antibiotic usage, infections and perform infection surveillance for six of the twelve months reviewed. This failure placed all residents at risk for potential transmission of infections and communicable diseases. The facility census was 16.
- 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 interviews, record review, and facility policy review, the facility failed to review and revise a comprehensive person-centered care plan for 1 (Resident (R)17) of 10 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to revise the comprehensive care plan for R17 after a pressure ulcer was identified.
Fire safety inspections
4 fire safety citations on file: 1 on October 10, 2024, 3 on May 18, 2023.
Every fire safety citation4 citations
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · May 18, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · May 18, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 18, 2023 · Corrected (the home has a date of correction)