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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
1E
0F
Potential for minimal harm
0A
0B
0C
July 2, 2026Standard inspection, Complaint inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide personal privacy during activities of daily living (ADL) care when Geriatric Care Aide (GCA) #1 video recorded Resident #81 with her cellphone while in the room during care without resident representative consent. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident # 81).
May 12, 2025Standard inspection, Complaint inspection · 3 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 record review and staff, Resident, and Resident Representative interviews, the facility failed to develop and implement a comprehensive care plan for a resident with a shellfish allergy. This was for 1 of 3 residents reviewed for dietary allergies (Resident #63).
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on record reviews, and interviews with the Resident, Resident Representative, and staff, the facility failed to obtain a resident's dietary allergies prior to serving food to a resident that would create an allergic reaction. This was for 1 of 3 residents (Resident #63) reviewed for food allergies and preferences.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their policy for enhanced barrier precautions (EPB) when Nurse Aide #1 and Nurse Aide #2 failed to wear a gown when providing incontinence care for Resident #14. This was for 2 of 9 staff members observed for infection control practices.
April 4, 2024Standard inspection, Complaint inspection · 6 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 observation and staff interviews, the facility failed to remove an expired food item stored for use in 1 of 1 refrigerated walk-in storage cooler. This practice had the potential to affect food served to residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and staff interviews the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for 1 of 3 residents reviewed for beneficiary protection notification who required the provision of the SNF-ABN form (Resident #40).
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on staff interviews and record review the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who discharged from hospice services for 1 of 1 resident reviewed for hospice care. (Resident #55)
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interviews and record review the facility failed to accurately code the hospice status of a resident on a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice care. (Resident #55)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review, and resident and staff interviews the facility failed to provide nail care to 1 of 2 dependent residents (Resident #167) reviewed for activities of daily living (ADL) care.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation survey of 10/28/21, and the recertification and complaint investigation survey of and 3/22/23. This was for re-cited deficiencies in the areas of Medicaid/Medicare Coverage/Liability Notices (F582) and Accuracy of Assessments (F641) The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.
Fire safety inspections
6 fire safety citations on file: 2 on May 12, 2025, 2 on April 4, 2024, 2 on March 22, 2023.
Every fire safety citation6 citations
- 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 · May 12, 2025 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 12, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 4, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 22, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 22, 2023 · Corrected (the home has a date of correction)