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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
3E
2F
Potential for minimal harm
0A
0B
0C
September 4, 2025Standard inspection · 0 citations
August 2, 2024Standard inspection · 0 citations
May 3, 2023Standard inspection · 7 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and policy review, the facility failed to ensure that an infection prevention and control program was implemented in order to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff followed an infection prevention and control cleaning program for an area identified as high risk (the kitchen ice machine) for the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building water system and cause lung infections) within the facility. Review of the facility policy, Legionella Water Management Program (Legionella), undated, indicated the following: -Kitchen ice machine: clean monthly per the manufacturer's instructions. Review of the Equipment Maintenance Log, Ice Machine, undated, indicated the following dates of inspection: [...]
- F
Report COVID19 data to residents and families.
Inspectors wroteBased on record review and interview, the facility failed to notify residents, families, and/or resident representatives of COVID-19 positive staff cases that occurred in the facility by 5:00 P.M., the next calendar day during the recent COVID-19 outbreak in April 2023, as required.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure its staff provided an environment as free of accident hazards as possible, relative to hot water temperatures, in two out of three resident unit hallways. Specifically, the facility failed to ensure its staff provided safe hot water temperatures in resident care areas when the facility water temperature was increased for running the dish machine, which also increased the water temperature on resident units, increasing the risk for injury of accidental burns.
- 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, policy review, and interview, the facility failed to adhere to food storage requirements in the main kitchen and dining room nourishment kitchen, and practiced standard sanitary procedures during food handling. Specifically, the facility staff failed to: 1. Label, date, and seal open food items meant for resident consumption in the main kitchen's dry storage area and refrigerator, 2. seal open food items stored in the dining room nourishment kitchen, and 3. wear hair restraints to fully cover hair during food handling and meal service.
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on record review and interview, the facility failed to implement requirements relative to outbreak testing and return to work testing criteria, in order to prevent the spread of infection, when the facility experienced an outbreak of COVID-19. Specifically, the facility failed to: 1. Initiate outbreak testing timely for one staff (Nurse #2), out of three sampled staff, 2. Complete outbreak testing every 48 hours until the facility went 7 days without a new case for three Residents (#17, #33 and #46), out of a sample of three residents, and 3. Document a negative test result for one staff member (Employee #1) prior to his/her return to work after testing positive for COVID-19.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on record review, policy review and interviews, the facility failed to arrange an Optometry appointment for one Resident (#33) out of a total sample of 12 residents. Specifically, the facility failed to address the Resident's vision impairment.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an accurate clinical record for one Resident (#8) out of a total sample of 12 residents. Specifically, facility staff failed to maintain an accurate record relative to: a. the Resident's use of CPAP [continuous positive airway pressure]: machine that uses a predetermined pressure to keep the airways open during sleep) and b. the Resident's physical status when his/her Diazepam (medication used to treat anxiety) was not administered due to the Resident being sedated.
Fire safety inspections
7 fire safety citations on file: 2 on September 4, 2025, 3 on August 2, 2024, 2 on May 3, 2023.
Every fire safety citation7 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 4, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 4, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 2, 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 · August 2, 2024 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · May 3, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 3, 2023 · Corrected (the home has a date of correction)