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 2 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
1D
1E
0F
Potential for minimal harm
0A
0B
0C
July 17, 2025Standard inspection · 0 citations
August 15, 2024Standard inspection · 0 citations
October 26, 2023Standard inspection · 2 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, staff interviews and facility policy review, the facility failed to maintain proper food handling practices while serving food for 4 out of 5 meals observed and failed to restrain hair for 3 out of 5 meals observed. The facility reported a census of 61 residents. Findings Include: 1. On 10/23/23 the following observations made during a lunch meal service in the Lynch Dining Room (DR): a. At 12:16 PM Staff F, Food Service Worker served food while she wore a baseball styled hat while several inches of her braided hair hung over the front of both shoulders. Staff F used her gloved hands to to pick up plates from under the counter and with the same gloved hands picked up grilled cheese sandwiches from the pan and placed them on plates. Staff used the same gloved hands to use the scoops to serve the rest of the items. b. [...]
- 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 interviews and facility policy review, the facility failed to revise a Care Plan to accurately reflect a Physician Order for a diet change for 1 of 3 residents reviewed for diets (Resident #17), and failed to revise a Care Clan to accurately reflect the risks of utilizing high-risk medications for 1 of 5 residents reviewed for medications taken (Resident #26). The facility reported a census of 61 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment completed for Resident #17, dated 8/22/23 documented the resident severely cognitive impaired. A Telephone Order signed by the physician dated 8/24/23 documented a Physician Order for diet ground meat and mechanical soft. A review of Resident #17's Care Plan documented the resident received a pureed diet. 2. [...]
Fire safety inspections
9 fire safety citations on file: 4 on July 17, 2025, 1 on August 15, 2024, 4 on October 26, 2023.
Every fire safety citation9 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 17, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 17, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 15, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · October 26, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 26, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 26, 2023 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 26, 2023 · Corrected (the home has a date of correction)