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 4 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
2C
July 25, 2025Standard inspection · 1 citation
- C
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteEntrance conference worksheet documents required for survey were not received timely. Based on record review and interviews during the recertification survey conducted 7/23/2025-7/25/2025, the facility did not make available clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for all 15 residents of the facility. Specifically, upon survey entrance, resident-identifiable information including form CMS-802 Matrix for Providers, and an alphabetical listing of all residents was not provided to the Department of Health in a timely manner. Additional information needed from the facility within one hour and four hours of entrance was not provided in a timely manner.
March 13, 2024Standard inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview during the recertification survey conducted 3/11/2024-3/13/2024 the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 11 of 11 residents (Residents #1, 106, 107, 108, 109, 110, 111, 112, 113, 114, and 115) reviewed. Specifically, the facility did not have an infection prevention control program including standards, policies and procedure that were current, specific to the resident population, and reviewed at least annually.
- C
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interview and record review during the recertification survey conducted 3/11/2024-3/13/2024 the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 of 11 residents residing on the unit. Specifically, administration did not ensure the facility appropriately outlined the roles of the required administrative staff and that they had developed specific policies and procedures for resident care that were reviewed annually. Additionally, deficiencies related to Administration were identified in the area of infection control (F 880).
December 29, 2021Standard inspection · 1 citation
- D
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 during the recertification survey conducted 12/28/21-12/29/21, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety for 1 of 2 kitchen areas (main kitchen). Specifically, the facility failed to remove expired food items and maintain clean surfaces in the main kitchen.
Fire safety inspections
13 fire safety citations on file: 6 on July 25, 2025, 4 on March 13, 2024, 3 on December 29, 2021.
Every fire safety citation13 citations
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · July 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · July 25, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · July 25, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 25, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · July 25, 2025 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 25, 2025 · Corrected (the home has a date of correction)
- D
Establish staff and initial training requirements.
E 37 · March 13, 2024 · Corrected (the home has a date of correction)
- D
Install a two-hour-resistant firewall separation.
K 133 · March 13, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 13, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 13, 2024 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · December 29, 2021 · Corrected (the home has a date of correction)
- D
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · December 29, 2021 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · December 29, 2021 · Corrected (the home has a date of correction)