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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
2E
0F
Potential for minimal harm
0A
0B
0C
December 30, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews, the facility failed to repair or replace broken floor tiles in 3 of 6 residents' rooms reviewed for a safe, comfortable and homelike environment. Findings Included During an observation on 12/30/2025 at 9:25 AM in room [ROOM NUMBER], there were four cracked floor tiles with brown discoloration adjacent to the doorway on the interior of the room, with one of the tiles raised slightly above the floor level. (Photographic evidence obtained). During an observation on 12/30/2025 at 9:38 AM in room [ROOM NUMBER], one cracked floor tile was observed adjacent to the doorway in the interior of the room (Photographic evidence obtained). [...]
April 17, 2025Standard inspection · 2 citations
- 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 observations, interviews, and record reviews, the facility failed to implement a person-centered comprehensive plan of care for 2 of 4 residents reviewed for respiratory care services. (Resident #212 and #24)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that respiratory care and services were provided consistent with professional standards of practice for 2 of 4 Residents (Resident #212 and Resident #24).
October 3, 2024Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's physician and resident's representative were notified of a change in condition for 1 of 3 residents reviewed for change in condition, Resident #1.
February 1, 2024Standard inspection · 8 citations
- E
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 record review, the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in 2 of 2 nourishment areas. Findings Include: A tour of the facility nourishment rooms was completed on 1/29/24 beginning at 9:48 AM with the Certified Dietary Manager (CDM). On 1/29/24 at 10:15 AM in the east nourishment room freezer there was an opened, unlabeled, undated container of Mystic Bahama Blueberry drink, an unlabeled, undated ½ eaten bar of a chocolate [NAME] Daz Ice cream on a stick, 3 bags of unlabeled, undated brown frozen bananas, 1 unlabeled, undated cheddar broccoli casserole, 2 unlabeled Styrofoam cups filled with an unidentifiable substance, and there was a reddish-brown sticky substance on the interior of the freezer bottom shelf. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 1 (Resident #31) of 4 residents reviewed for respiratory care and 1 (Resident #96) of 4 residents reviewed for discharge.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents who required blood glucose monitoring receive treatment in accordance with professional standards of practice for 1 of 3 residents review for insulin administration (Resident #77) and failed to promptly notify a physician for critical high laboratory results for 1 of 3 resident reviewed for laboratory results ( Resident #108)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to administer oxygen according to physician's orders and professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #82 and #30)
- 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 observations, interviews, and record review, the facility failed to label and store medications according to professional standards of practice in 2 of 4 medication carts.
- 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 and review of the facility policy and procedure the facility failed to accurately and completely document within the medical record for 2 out of 3 residents reviewed for insulin administration (Resident #77 and #95).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and record review the facility failed to perform hand hygiene during medication administration in 2 out of 5 observations consistent with accepted standards of practice.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain equipment to be in a safe operating condition for 1 reach in refrigerator in the main kitchen.
August 11, 2022Standard inspection · 5 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during medication administration in 5 of 6 observations of medication administration.
- 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, the facility failed to conduct and submit a discharge Minimum Data Set (MDS) assessment within 14 days after completion to the Centers for Medicare Services System, including a subset of items upon a resident's transfer, or discharge for 2 (Resident #1 & Resident #2) out of 3 residents sampled for MDS assessment completion.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services that meet professional standards of quality related to the application of compression stockings for 1 (Resident #86) out of 1 resident sampled for use of compression stocking and performing wound dressing care for 1 (Resident #202) out of 3 residents sampled for wound care. Findings Include: 1. Review of the admission Record for Resident #86 documented the resident was initially admitted to the facility on [DATE] and has a diagnosis of heart failure (a condition that causes fluid buildup in the feet, arms, lungs, and other organs). Review of the physician orders for Resident #86 documented an order placed on 05/12/2022 that read compression stockings two times a day for edema. During an observation on 08/08/2022 at 9:47 AM, Resident #86 was not wearing compression stockings. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1 (Resident #25) of 2 central venous access devices out of a total sample of 43 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrote2. During an observation on 08/08/22 at 8:32 AM Resident #47 was observed lying on her left side in bed with oxygen being administered at 1 liter via nasal cannula. During an observation on 08/09/22 at 10:27 AM Resident #47 was observed sitting in bed with oxygen being administered at 1 liter via nasal cannula. Review of the admission Record for Resident #47 documented the resident was admitted to the facility on [DATE] with the following diagnosis: chronic respiratory failure (Low oxygen levels that impact breathing) and congestive heart failure (the heart cannot pump enough blood to meet the body's needs). Review of the Physician Orders for Resident #47 dated 6/7/22 reads: Oxygen 2-4 liters/min to maintain oxygen % (percentage) saturation above 92% as needed for shortness of breath/low oxygen level. [...]
Fire safety inspections
28 fire safety citations on file: 6 on April 17, 2025, 1 on February 1, 2024, 21 on August 11, 2022.
Every fire safety citation28 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 17, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 17, 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 · April 17, 2025 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · April 17, 2025 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · April 17, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 1, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Address patient/client population and determine types of services needed.
E 7 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Include a process for Emergency Preparedness collaboration.
E 9 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Address subsistence needs for staff and patients.
E 15 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for sheltering.
E 22 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for medical documentation.
E 23 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Establish policies and procedures for volunteers.
E 24 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Establish roles under a Waiver declared by secretary.
E 26 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Develop a communication plan.
E 29 · August 11, 2022 · Corrected (the home has a date of correction)
- E
List the names and contact information of those in the facility.
E 30 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Provide primary/alternate means for communication.
E 32 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Establish methods for sharing information.
E 33 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Provide a means of sharing information on occupancy/needs.
E 34 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Provide family notifications of emergency plan.
E 35 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 11, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Provide hallway or ground-level exits in all residents' rooms.
K 254 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 11, 2022 · Corrected (the home has a date of correction)