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
8D
0E
0F
Potential for minimal harm
0A
0B
0C
November 20, 2025Standard inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to report an allegation of potential financial exploitation to the State Agency for 1 of 14 residents reviewed (Resident #33). The facility reported a census of 33 residents.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on clinical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner following admission to hospice care for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 33 residents.
September 19, 2024Standard inspection · 0 citations
April 11, 2024Complaint inspection · 1 citation
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to provide the tube feeding (TF) according to the physician's order individualized to the resident for 1 of 1 residents reviewed with tube feeding sampled (Resident #3). The facility reported a census of 32 residents.
June 22, 2023Standard inspection · 5 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 clinical record review,staff interviews, and facility policy review the facility failed to complete a Comprehensive Care Plan for 1 of 12 residents in the sample (Resident #3). The facility reported a census of 38 residents.
- 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 clinical record review, staff interview and facility policy review, the facility failed to revise/update the Comprehensive Care Plan after a resident experienced a significant change; and another resident had a fall for 1 of 12 residents (Resident #3). The facility reported a census of 38 residents.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on clinical record review, Menu review, observations and staff interview the facility failed to ensure foods were pureed to ensure appropriate portion size for two of three residents who received a pureed diet (Residents #9 and #17). The facility reported a census of 38 residents. Findings Include: Review of the Diet List revealed two residents, Resident #9 and Resident #17, received a pureed diet. The Physician Order for Resident #9 dated 8/24/22 documented, Regular diet pureed texture, regular consistency, thin liquids as tolerated with supervision. The Physician Order for Resident #17 dated 4/27/20 documented, Regular diet pureed texture, regular consistency, regular liquids. May have finger food per resident preferences. Review of the Menu for the noon meal for Week 2 Tuesday revealed the regular diet included #8 scoop of sweet pepper slaw. [...]
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to screen residents for eligibility of the pneumococcal vaccine for 1 of 5 residents reviewed. (Resident #30). The facility reported a census of 38 residents.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to educate staff on the benefits of the COVID-19 vaccination and provide information on obtaining the vaccination. Findings Include: The facility presented a list of facility staff that documented staff vaccination status. On the list is a handwritten highlighted [yellow] = not vaccinated notation. During an interview on 6/22/23 at 12:45 PM, the Administrator stated the list is used to track staff COVID-19 vaccination status. The list revealed a total of 54 staff, with 11 highlighted to indicate not vaccinated for COVID-19. During an interview on 6/22/23 at 10:20 AM, the Infection Preventionist (IP) stated the Business Office Manager (BOM) completes a surveillance of staff COVID -19 vaccination status at hire. [...]
Fire safety inspections
14 fire safety citations on file: 3 on November 20, 2025, 3 on September 19, 2024, 8 on June 22, 2023.
Every fire safety citation14 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 20, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 20, 2025 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · November 20, 2025 · Corrected (the home has a date of correction)
- F
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 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 19, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · June 22, 2023 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · June 22, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · June 22, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 22, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 22, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 22, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 22, 2023 · 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 22, 2023 · Corrected (the home has a date of correction)