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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
2E
3F
Potential for minimal harm
0A
0B
0C
December 4, 2025Standard inspection · 2 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, interview and record review, the facility failed to ensure hairnets were worn in the kitchen, failed to ensure all in-use dishwasher machines reached the required dish surface sanitation temperature during the rinse cycle, failed to ensure opened food items in the refrigerator and freezer were dated and labeled, failed to ensure food items were kept off of the floor in the kitchen, failed to complete and record cool down temperatures for food items that were prepared ahead and stored for future use, and failed to ensure the ceiling in the kitchen was kept clean and free of debris and dust. These failures have the potential to affect all 45 residents residing in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview the facility failed to ensure a MDS (Minimum Data Set) Assessment was accurately completed for one of one resident (R26) reviewed for MDS accuracy in the sample of 21.
February 20, 2025Standard inspection · 5 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, interview and record review, the facility failed to ensure safe and sanitary kitchens to prevent foodborne illnesses. This failure has the potential to affect 48 residents who reside in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure required Personal Protective Equipment was donned prior to entering a COVID Positive Resident (R33) Room. This failure has the potential to affect all 12 residents (R1, R7, R8, R11, R17, R22, R23, R28, R3, R36, R38, R43) who reside in R33's Household Unit. The facility also failed to follow Enhanced Barrier Precautions and ensure required Personal Protective Equipment was donned during cares for two residents (R14 and R29) of 12 residents reviewed for direct cares in a total sample of 31.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority to reevaluate a resident with a significant change in mental status for one of two residents (R20) with a significant change in mental status in a sample of 31 residents.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review the facility failed to have documented rationale or appropriate diagnosis for the use of an antipsychotic for one (R101) of five residents reviewed for unnecessary medications in the sample of 31.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R34) reviewed for Hospice care management in a sample of 31 residents.
March 20, 2024Standard inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and interview the facility failed to effectively monitor all infections in the facility. This failure has the potential to affect all 54 residents who currently reside in the facility. Finding Include: The Facility's Infection Control Policy dated 01/11/2024 documents The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to the regulatory requirements and follow accepted national standard. Surveillance: A system of surveillance designed to identify possible communicable disease or infections before they can spread to other persons in the facility. [...]
September 15, 2023Complaint inspection, Infection control · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to report, track and perform COVID-19 testing of an employee that displayed COVID-19 like symptoms prior to providing services to 11 residents (R4 through R14) of 17 residents reviewed for COVID-19 in a sample of 14.
Fire safety inspections
9 fire safety citations on file: 2 on December 4, 2025, 2 on February 20, 2025, 5 on March 20, 2024.
Every fire safety citation9 citations
- F
Address subsistence needs for staff and patients.
E 15 · December 4, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · December 4, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 20, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 20, 2024 · Corrected (the home has a date of correction)
- E
Install a two-hour-resistant firewall separation.
K 133 · March 20, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 20, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 20, 2024 · Corrected (the home has a date of correction)