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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
2D
0E
2F
Potential for minimal harm
0A
0B
0C
August 27, 2025Standard inspection · 1 citation
- 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 interview, the facility did not notify the Ombudsman of a resident who was transferred from the facility to a hospital for 1 of 3 residents (R) (R1) reviewed. The facility policy, titled Notification of Changes, dated 03/32/2017, states, The facility will notify the proper parties when changes occur. Under Section 5(a)(1) states in part, The facility will send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman program when there is an appeal to the discharge decision. R1 was admitted to the facility on [DATE]. On 06/27/25, R1 had a change in condition and was transferred to the hospital. A Bedhold and Notice of Transfer form was provided to R1. On 08/26/2025 at 2:58 PM, Surveyor requested Ombudsman notification of hospital transfer with return anticipated. [...]
June 20, 2024Standard inspection · 2 citations
- G
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 interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition post procedure. This occurred for 1 of 4 residents (R15) reviewed for physician notification and consultation. R15 presented with new symptoms of lethargy and fever post ureteral stent placement. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents (R) receive treatment and care in accordance with professional standards of practice for residents experiencing changes in condition for 1 of 4 residents (R15) reviewed for changes in condition. The facility did not properly assess R15 post ureteral stent (a thin tube that's inserted into the ureter to treat or prevent blockages that prevent urine from flowing from the kidney to the bladder) placement. This is evidenced by: The facility policy, entitled Monitoring Protocol Post Procedure, states: After readmission to the facility postoperatively, . [...]
May 17, 2023Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility did not maintain 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. This had the potential to affect all 28 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system. - Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met. - Include a process to confirm the WMP is being implemented and is effective. - Document and communicate all the activities. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and record review, the facility did not have a system in place to maintain the scale inhibitor for the Rational oven per manufacturer's guidelines. This has the potential to affect all 28 residents in the facility. The facility had no system to ensure changing of the scale inhibitor filter, causing malfunction of the Rational oven. [NAME] repairs, the facility did not implement a system to ensure routine maintenance was completed for the oven. This is evidenced by: On 05/17/23 at 10:40 AM, Surveyor asked the Culinary Supervisor (CS) F about the scale inhibitor filter for the Rational oven (kitchen equipment that cooks the food in varying ways such as steaming). Surveyor asked CS F when the scale inhibitor filter was last changed. CS F said he does not know when it was last changed. [...]
Fire safety inspections
6 fire safety citations on file: 2 on August 27, 2025, 3 on June 20, 2024, 1 on May 17, 2023.
Every fire safety citation6 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 27, 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 · June 20, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 20, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 20, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 17, 2023 · Corrected (the home has a date of correction)