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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
4E
0F
Potential for minimal harm
0A
0B
0C
January 23, 2026Standard inspection, Complaint inspection · 2 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interviews with resident, staff, pharmacy and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #2).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on records review, and staff interviews, the facility failed to implement the abuse policy and procedure in the area of reporting when the facility failed to report an abuse allegation to the State Agency within the specified timeframes, and failed to notify the Adult Protection Services (APS) for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #2).
October 10, 2024Standard inspection, Complaint inspection · 3 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, and staff interviews, the facility failed to store food in the walk-in freezer not open to air and without freezer burn. The facility failed to discard foods past their use-by date, failed to label and date food placed in the nourishment refrigerator in 1 of 2 nourishment refrigerator/freezers reviewed for food storage (E/F hallway). The facility also failed to hold cold foods in a safe temperature range during tray line observation. These practices had the potential to affect food being served to the residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to treat a resident with dignity and respect when a nurse aide was witnessed yelling at a resident during an interaction in the resident's room for 1 of 4 residents reviewed for dignity (Resident #75). A reasonable person expects to be treated with respect and dignity by their caregivers in their home environment.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to apply signage indicating the use of oxygen outside residents' rooms with supplemental oxygen for 1 of 2 residents reviewed for respiratory care (Resident # 79).
July 28, 2023Standard inspection · 3 citations
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, Responsible Party and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 sampled resident (Residents #8) reviewed for grievances. This practice occurred for 6 grievances filed on behalf of Resident #8.
- 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, and staff interviews the facility failed to maintain the walk-in refrigerator floor and racks in clean condition, label foods and discard foods that were spoiled. The facility failed to maintain the double stack oven clean and without grease build up. The facility failed maintain food in the walk-in freezer without freezer burn. The facility also failed to hold hot food (equal to or greater than 135 degrees Fahrenheit (F) on the steam table during tray line observation. The facility failed to ensure a male dietary staff had all facial hair contained in a face covering. These practices had the potential to affect food being served to residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the 7/19/22 complaint investigation survey. This was for one recited deficiency of F812 Food Procurement, Store/Prepare/Serve - Sanitary. This deficiency was cited again during the annual recertification and complaint investigation survey of 7/28/23. This continued failure of the facility during two consecutive surveys shows a pattern of the facility's inability to sustain an effective QAA program.
Fire safety inspections
20 fire safety citations on file: 8 on January 23, 2026, 3 on October 10, 2024, 9 on July 28, 2023.
Every fire safety citation20 citations
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 23, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 23, 2026 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · October 10, 2024 · Corrected (the home has a date of correction)
- 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)
- D
Have proper medical gas storage and administration areas.
K 923 · October 10, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 28, 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 · July 28, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 28, 2023 · 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 · July 28, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · July 28, 2023 · Corrected (the home has a date of correction)
- 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 · July 28, 2023 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · July 28, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 28, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 28, 2023 · Corrected (the home has a date of correction)