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
5D
1E
2F
Potential for minimal harm
0A
0B
0C
December 16, 2025Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, interview, and facility policy review, it was determined that the facility failed to ensure that staff maintained sterility during deep tracheal suctioning and failed to ensure staff performed proper hand hygiene while providing resident care for one resident, Resident #1 reviewed for tracheal suctioning and trach care.
February 11, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interviews, and facility policy review the facility failed to ensure staff donned the proper Personal Protective Equipment (PPE) while providing care to 1 (Resident #7) on Enhance Barrier Precautions of 3 sampled residents selected for a complaint against the facility for quality of care/treatment.
December 4, 2024Complaint inspection · 1 citation
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented to meet a resident's needs for 1 (Resident #4) of 3 sampled residents reviewed for Respiratory/Tracheostomy (Trach) care.
July 25, 2024Standard inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods in the freezer and storage room were covered, sealed and dated to maintain freshness and prevent potential cross contamination; and expired food items foods were promptly removed from stock to maintain freshness and prevent potential cross contamination; dietary staff practiced good hand washing techniques to prevent potential cross contamination of food and clean dishes.
- E
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 observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 2 of 2 meals observed.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure the residents' decisions as to whether they desired to have, or not have, an advanced directive, were documented in a prominent part of the clinical record to ensure their wishes were known regarding acceptance or rejection of any life-sustaining treatments in the event of their incapacitation for 1 (Resident #154) of 1 sampled resident whose clinical records were reviewed for advanced directive information.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview, and record review, the facility failed to ensure an Advanced Beneficiary Notice (ABN) was provided, as required, to allow the resident and/or the resident representative family, decide if the resident wishes to continue receiving skilled services that may not be paid for by Medicare; and of their financial liability for care and services after the Medicare coverage was discontinued for 1 (Resident #3) sampled resident.
July 20, 2023Standard inspection · 1 citation
- F
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 interview, the facility failed to ensure expired beverage/food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen and hot food items on the steamtable were maintained at a temperature at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 40 residents who received meals from the Kitchen (Total Census: 40), according to the list provided by the Dietary Supervisor on 07/17/23 at 3:40 PM.
Fire safety inspections
6 fire safety citations on file: 3 on December 16, 2025, 3 on July 25, 2024.
Every fire safety citation6 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 16, 2025 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · December 16, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · December 16, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 25, 2024 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · July 25, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 25, 2024 · Corrected (the home has a date of correction)