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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
2E
1F
Potential for minimal harm
0A
0B
0C
September 15, 2025Standard inspection · 7 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 and interview conducted during a Recertification Survey the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, undated and unlabeled food items were observed in multiple freezers and refrigerator/s.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview during the recertification survey indicated that the facility did not provide residents with a clean, comfortable, and homelike environment. Specifically, multiple resident rooms showed signs of maintenance issues, including spackle and chipped paint, stained and sticky floors, an unpleasant odor, missing blinds, cabinets with chipped paint, black streaks on doors, and a white tint on a window. Furthermore, there was damage to the left armrest of Resident #74's wheelchair, and the wheelchair/seat cushion were soiled with white particles.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not ensure care was provided in a manner to maintain dignity and privacy for one (1) of (2) two residents (Resident #4) reviewed for dignity. Specifically, Resident #4 was observed undressed in bed with their body fully exposed and visible from the hallway.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview during the recertification survey the facility did not ensure the residents right to personal privacy, including the right to promptly receive a package delivered to the facility for the resident, including those delivered through a means other than a postal service for one (1) of three (3) residents (Resident #33) reviewed for choices. Specifically, 1) the facility did not promptly deliver a package within 24 hours to Resident #33 after it had been shipped to and received by the facility.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not ensure that needed equipment was provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for one (1) of (4) residents (Resident # 50) reviewed for position and mobility. Specifically, Resident #50 was observed on three occasions without the use of a physician prescribed left elbow extension splint and left-hand roll.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review and staff interview during the Recertification Survey the facility did not ensure that they adequately maintained an infection control program designed to provide a safe and sanitary environment for one (1) of two (2) residents (Resident #3) reviewed for pressure ulcers and that a Legionella sampling and water management plan for its potable water system was adopted and implemented. Specifically, (1) Registered Nurse #3 touched surfaces and then without performing hand hygiene handled guaze that was used to clean Resident #3's wound and (2) the facility did not provide a water management and sampling plan at the time of survey.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on observation, record review and interview conducted during the recertification survey the facility did not ensure infection control prevention practices were maintained to prevent development and transmission of communicable diseases and infection for all residents. Specifically, there was no documented evidence of COVID-19 education, COVID-19 vaccination administration and/or COVID-19 declination for two (2) of ten (10) staff (Certified Nurse Aide #20 and Licensed Practical Nurse #21) reviewed for COVID-19 vaccination.
December 4, 2023Standard inspection · 4 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, interview, and record review, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. Two heavily soiled circulation fans were in use, one in a food production area and one at the clean side of the dishwasher, 2. a. kitchen staff used their bare hand to retrieve a piece of aluminum foil that had fallen into a pan of chicken and gravy, and b. a soiled and peeling food cart was in use for holding cooked foods, 3. 1 of 3 nourishment refrigerators contained multiple unlabeled and expired food items, 4. a. For 2 of 2 microwaves for use on the resident units ([NAME] and Maple Avenue), there were no thermometers available to check food temperatures and b. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, record review and interview during the recertification survey from 11/28/23 to 12/4/23, the facility did not ensure residents had the right to a dignified existence in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 5 residents (Resident #46) reviewed for dignity. Specifically, Resident #46 had a sign next to their bed stating walk me every day.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 11/28/23 to 12/4/23, it was determined the facility did not ensure maintenance services necessary to maintain a safe, clean, comfortable and homelike environment were provided for 1 of 1 resident (Resident #40) reviewed for environment. Specifically, Resident #40's room had an accordion style bathroom door that was falling off the track.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observations, interviews, and record review during the recertification survey from 11/28/23 to 12/4/23, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their mobility for 1 of 1 resident (Resident #65) reviewed for Activities of Daily Living (ADLs). Specifically, nursing staff did not ensure Resident #65's progressive mobility was maintained in accordance with the providers orders and professional standards.
October 13, 2020Standard 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 observations, interviews and record review conducted during a recertification survey, it cannot be ensured that the facility stored food in resident refrigerators according to professional standards for food safety to prevent foodborne illness. Specifically, foods stored in 2 of 3 unit refrigerators (First and Second Floors) were not labeled with the resident's name or the date the item was brought to the facility.
Fire safety inspections
26 fire safety citations on file: 11 on September 15, 2025, 10 on December 4, 2023, 5 on October 13, 2020.
Every fire safety citation26 citations
- F
Use approved construction type or materials.
K 161 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 15, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 15, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · September 15, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 15, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · September 15, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 15, 2025 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · September 15, 2025 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · September 15, 2025 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 4, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 4, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 4, 2023 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · December 4, 2023 · fire safety evaluation s
- D
Install proper backup exit lighting.
K 281 · December 4, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · December 4, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 4, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 4, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 4, 2023 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 4, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · October 13, 2020 · Corrected (the home has a date of correction)
- D
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
K 224 · October 13, 2020 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 13, 2020 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · October 13, 2020 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · October 13, 2020 · Corrected (the home has a date of correction)