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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
16E
3F
Potential for minimal harm
0A
1B
0C
November 19, 2025Complaint inspection · 1 citation
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, resident representative interview, and staff interview, the facility failed to implement their grievance policy procedure to locate lost clothing and follow-up with resident/resident representative in a timely fashion. Resident identifier: #31. Facility census: 65.
September 10, 2025Standard inspection, Complaint inspection · 9 citations
- K
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on record review, staff interview and observations, the facility failed to ensure residents were served food in the correct consistency according to the facility's diet description for puree consistency solids. It was determined that this failed practice placed all (5) five residents currently on a puree diet in an immediate jeopardy situation. Providing a resident with the wrong consistency of food could result in choking, and/or aspiration pneumonia which can lead to serious harm and/or death. This failed practice was found to be true for five (5) of five (5) residents reviewed for diet consistency during the Long-Term Care Survey Process. Resident Identifiers: #12, #21, #33, #38, and #53. Facility Census: 65. Findings Include: a) Puree diets A record review on 09/08/25 at 11:00 AM, revealed a diet order for Resident #38 that read as follows:Regular/Liberalized-Dys Puree. [...]
- 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 staff interview, the facility failed to ensure it had a clean, comfortable, homelike environment. This deficient practice was a random opportunity for discovery. Resident identifiers: #18, #3, #32. Facility census: 65.
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure it notified the Ombudsman of discharges/transfers. This was true for three (3) of seven (7) residents. Resident Identifiers: #72, #71,and #68. Facility Census: 65. a) Resident #72 09/10/2025 8:54 AM record review revealed Resident #72 was discharged to another skilled nursing facility on 08/02/24. The review of this discharge revealed no evidence that the Ombudsman was not notified of Resident #72's discharge. This was discussed with Employee #89. b) Resident #71 On 09/09/25 at 9:10 PM Resident #71 a review of the discharge record found no evidence that the Ombudsman had been notified of the discharge. c) Resident #68 A review of the discharge record on 09/04/25 at 11:21 AM found Resident #68 had been transferred to a local hospital and was discharged from the facility on 08/04/25. [...]
- 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 staff interview, the facility failed follow the menus by not serving the correct serving sizes per the dietary guide sheet, not serving the residents large portions as ordered by the physician and serving items listed on the tray card not to serve. Resident Identifiers: #36, #61, #53, #4 and #21. Facility Census: 65.
- 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 interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 65.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview and record review the facility failed to maintain an infection prevention program to provide a safe, sanitary and comfortable environment to help prevent the transmission of infections. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier #43. Facility Census 65.a) Laundry On 09/09/25 at 2:45 PM a tour of the facility laundry was conducted with the Regulatory Compliance Advisor (RCO) and the Laundry Supervisor. A basket full of clean socks was found stored on the floor in the clean laundry. The Laundry Supervisor was asked if the clean socks were stored to prevent contamination, he responded No. In the soiled laundry, there were three (3) open bags of soiled laundry on the floor. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure a updated Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a new diagnosis of Bipolar Disorder. Resident Identifier: #11. Facility Census: 65.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure a resident with limited Activities of Daily Living (ADL) ability was provided the necessary services to maintain grooming by assisting with facial hair removal. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #36. Facility Census: 65. a) Resident #36On 09/02/25 at 5:42 PM, the state surveyor observed facial hair on Resident # 36 during the initial survey interview process. The patient reported he did not want the facial hair and stated, I want it shaved. and They need to do it. Nursing Assistant #12 confirmed the resident's facial hair growth and stated she would get it shaved.09/09/25 at 8:45 AM, the resident was observed to still have facial hair. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide care and services in accordance with professional standards of practice by not putting in physician orders timely related to skin issues. This failed practice was found true for (1) one (3) residents reviewed for general skin issues during the Long-Term Care Survey Process. Resident identifier #8. Facility Census 65.
July 11, 2024Standard inspection, Complaint inspection · 24 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure its residents were not abused. The facility failed to provide services to residents that were necessary to avoid mental or emotional harm. In addition, the facility failed to protect residents when verbal and physical threats were made. This was true for 1 (one) of 1 (one) resident reviewed during the Long-Term Survey Process. Facility census: 64. Resident identifier #42, and #61. This created an immediate jeopardy situation.
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote]Based on medical record review, and staff interview, the facility failed to follow up on physician's recommendations for a biopsy of Resident #29 thyroid nodules upon readmission to the facility on [DATE]. This was true for one (1) of nineteen (19) residents care reviewed during the long-term care survey process. This created a situation of immediate jeopardy. Resident identifier: Resident #29. Census: 64.
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on Record review and family and staff interview, the facility failed to ensure residents were provided with a safe environment to prevent elopement, resulting in Resident #120 leaving the facility and being found outside the facility, deceased . The facility ' s failure to ensure residents did not exit the facility unattended on [DATE] placed all at risk residents who could have exited the facility in an Immediate Jeopardy (IJ) situation. This will be cited at past noncompliance because the facility corrected the failure as of [DATE], prior to this survey. This was true for one (1) of six (6) residents reviewed for accidents and one (1) of three (3) reviewed for elopement during the survey process. Resident Identifier: 120. Facility census:
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on record review and staff interview, the facility failed to employ qualified dietary staff, due to letting employees work in the dietary department before obtaining food handler permits. This had the potential to affect all residents residing in the facility. Facility census: 64.
- 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 staff interview, the facility failed to store and prepare food in a sanitary manner, due to having items that were out of date and not dated in the refrigerators, items exposed to the elements, having dirty equipment, and failing to monitor refrigerator temperatures of personal refrigerators in resident rooms. This has the potential to affect all residents receiving food from the kitchen and all residents with personal refrigerators in their rooms. Facility census: 64.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, the facility failed to dispose of refuse in a manner to prevent attracting vermin. This has the potential to affect all residents residing in the facility. Facility census: 64.
- E
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 record review and staff interview the facility failed to review and revise the care plan for Resident #61's psychotropic medication, dementia, and behaviors. In addition the facility failed to revise the care plan to reflect weights no longer be obtained for Resident #59 and the care plan to reflect the surrogate for Resident #29. This was true for 3 (three) of 19 residents reviewed for the Long Term Care Survey process. Facility census: 64. Resident identifiers: #61,#59 and #29.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on record review, staff interview and resident interview, the facility failed to provide medically related social services for Resident #61 or residents that suffered abuse from Resident #61. This was true for 1 (one) of 3 (three) residents reviewed during the Long-Term Survey Process. Facility census: 64. Resident identifiers: Resident #61 and Resident #42.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, the facility failed to accurately document medication administration times on the Medication Administration Record (MAR) and medication sign out and administration times on the narcotic count sheet for Resident #28 ' s Morphine Sulphate. This was a random opportunity for discovery. Facility census: 64.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview, the facility failed to practice proper infection control to prevent the spread of communicable diseases during lunch service. This was a random opportunity for discovery. This has the potential to affect all residents residing in the facility. Facility census: 64.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, comfortable, homelike environment for residents, staff and the public. Issues were found with dead flowers and items being stored over on top of the over bed light fixture. In addition the facility did not have record of fire drills being completed as required. These were random opportunities for discovery during the long term care survey and has the potential to affect all of the residents. Room identifiers: #304, #307. Census: 64.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on medical record review and staff interview, the facility failed to confer with the appointed resident representative regarding the physician recommendation for medical treatment (biopsy of thyroid nodules) and the recommendation of the Registered Dietitian for nutritional support. This was true for one (1) of four (4)residents whose rights were reviewed during the long-term care process. Resident identifier: #29. Census: 64.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and staff interview, the facility failed to allow Resident #28 to participate in his care and make treatment decisions, by failing to inform him of his right to participate in hospice care. The facility also failed to notify the responsible party for Resident #61 of the potential side effects of a psychotropic medication before administration. This was true for two (2) of three (3) residents reviewed for the right to make informed decisions during the survey process. Resident identifiers: #28, #61. Facility census: 64.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, staff interviews and record reviews, the facility failed to implement two (2) of 19 resident's care plans. Resident #7's care plan was not implemented in the area of nutritional assistance. Resident #7 was not monitored or assisted with her meal for over one (1) hour after her meal was delivered. Resident #61 had no nutritional care plan developed despite having experienced weight loss. Resident identifiers: #7, #61. Facility census: 64.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility failed to address the needs of residents at risk or already experiencing impaired nutrition and hydration. The facility declined the Registered Dietician dietary recommendations without notifying the surrogate and failed to obtain weights. This was true for two (2) of four (4) residents reviewed for nutritional needs during the long term care survey process. Resident identifiers: Resident #29 and Resident #61. Census. 64. a) Resident #29- nutritional support During a medical record review on [DATE] at approximately 10:00 AM of Resident #29's medical record, it is identified that the resident has a Brief Interview for Mental Status (BIMS) of 06. It is further identified that the physician note completed on [DATE] stated that the patient was alert and oriented x 1 with no acute distress and that Resident #29 does not have capacity at this time. [...]
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on record review, staff interview and observation, the facility failed to follow physician's order related to volume of feeding to be administered to Resident #52. This was true for 1 (one) of 1 (one) resident reviewed for the Long-Term Care Survey Process. Facility census: 64. Resident identifier: #52.
- D
Post nurse staffing information every day.
Inspectors wroteBased on facility record review and staff interview, the facility failed to complete the Nurse staffing information accurately. Some of the data required was not completed, the direct care staff and the total actual hours worked by the direct care staff was inaccurate. This was true for nine (9) of ten (10) Nurse Staffing forms reviewed during the long term care survey process. Census: 24.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and staff interview, the facility failed to provide the necessary behavioral health care and psychiatric services to Resident #61. This was true for 1 (one) of 3 (three) residents reviewed for the Long Term Survey Process. Facility census: 64. Resident identifier: Resident #61.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on record review and staff interview, the facility failed to provide necessary appropriate person-centerd care and individualized treatment and services to meet Resident #61's behavioral and psychosocial needs. This was true for 1 (one) of 3 (three) residents reviewed for the Long Term Survey Process. Facility census: 64. Resident identifiers: Resident #61.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on record review and staff interview, the facility failed to provide an interdisciplinary approach to address Resident #61's needs and to provide the necessary services related to the diagnosis of dementia. This was true for 1 (one) of 3 (three) residents reviewed during the Long Term Care Survey Process. Facility census: 64. Resident identifier: Resident #61.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interview, the facility failed to monitor Resident #61 for side effects of psychotropic medication after administration of Zyprexa 10mg Intramuscularly (IM). This was true for 1(one) of 5 (five) residents reviewed for the Long Term Care Survey Process. Facility census: 64. Resident identifier: Resident #61.
- 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 record review and staff interview the facility failed to administer a as needed (PRN) psychotropic for a specifically diagnosed condition for Resident #61. This was true for 1 (one) of 5 (five) residents reviewed for the Long-Term Care Survey Process. Facility census: 64. Resident identifier: #61.
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteThe facility failed to make good faith attempts to identify deficiencies of which they had or should have had knowledge of. The Quality Assurance and Performance Improvement (QAPI) program implemented to correct the [NAME] Virginia Portable Order for Scope of Treatment (POST) form completions was not being modified correctly. This has the potential to affect all the residents residing in the facility that completes a POST form. This was identified during the long term care survey process. Identifier: POST forms. Census: 64 a) Post forms During a POST form document review of on 07/12/24 at approximately 04:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. It is further noted that to void a POST form the following must be completed; [...]
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on medical records, facility records and staff interview the facility Quality Assurance and Performance Improvement committee failed to develop corrective actions to effectively change systems level to prevent quality of care and or quality of life problems. The POST forms were not being accurately completed and or modified based on the physician's determination of capacity. All residents had the potential to be affected by this practice. This was discovered during the facilities long term care survey process. Census: 64. a) Post forms During a POST form document review of on 07/12/24 at approximately 4:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. It is further noted that to void a POST form the following must be completed; [...]
March 8, 2023Standard inspection · 11 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on resident interviews, staff interviews, and record review the facility failed to ensure sufficient qualified nursing staff are available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This has the potential to affect more than a minimal number of residents at the facility. Census 65. Findings Included: a) Anonymous Resident Interviews On 03/06/23 at 12:19 PM, an anonymous resident complained about having to wait a long time last night to get cleaned up and being left in urine for hours. On 03/06/23 at 1:57 PM, another anonymous resident stated he/she has to sit in their poo for hours, especially if it is meal time. The staff make residents wait until trays are served and picked back up before they will change the residents. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interview, resident council meeting and staff interview, the facility failed to serve food which was palatable and appetizing in appearance. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident identifiers: Resident #17, Resident #21, Resident #40, Resident #56 and Resident #5. Facility Census: 65. Findings Included: a) Resident #17 During the initial tour on 03/06/23 at 11:54 AM, Resident # 17 stated the food sucks, I eat the food that my friend brings me. You can not eat the food that is prepared here it is terrible. b) Resident #21 During the initial tour on 03/06/23 at 11:38 AM, Resident # 21 stated the food is bad, I am not offered a substitute if I don't like my meal. I just don't eat it. I have lost weight, because I don't eat. [...]
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, staff interview, resident interview, resident council meeting and previous minutes from resident council, the facility failed to provide Residents with evening snacks. This had the potential to affect more than a limited numbers of residents living in the facility that could receive snacks from the kitchen. Facility Census: 65. Findings Included: a) Nourishment Rooms During the tour of the Nourishment Room on 400 hall with the Account Manager (AM) on 03/07/23 at 8:13 AM the following snacks were reveled: -three (3) bags of chips left over from last night snack pass -eight (8) half sandwiches -pitches of purple drink, red drink and tea During the tour of the Nourishment Room on 200 hall with the AM on 03/07/23 at 8:18 AM the following snacks were revealed: [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, policy review and staff interview, the facility failed to ensure foods were stored and prepared in a safe, clean, and sanitary environment. The facility failed to ensure kitchen equipment, kitchen area and ice machine were clean and sanitary in a manner in accordance with professional standards for food service safety. The facility also failed to correctly document temperatures for the dish machine. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 65 Findings Included: a) The improper sanitization of kitchen equipment A review of a facility policy titled Equipment with a revised date 09/17 stated (typed a written): Procedures 1. All equipment will be routinely cleaned and maintained in accordance with manufacture's directions and training materials. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to maintain 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. The facility failed to place residents with active Multidrug-resistant organisms (MDRO) in Transmission Based Precautions (TBP) and provide proper hand washing practices during catheter care. Resident identifiers: R#4, #35, #22, #56, #1, and #117. Facility census 65.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation and staff interview, the facility failed to maintain an effective pest control program so the facility is free of rodents. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 65. Findings Included: a) Kitchen Tour An initial tour of the kitchen with the Account Manager(AM) #77 beginning on 03/06/23 at 10:31 AM, revealed the following: - A sticky mouse trap with a piece of fudge cake was found in the dry storage area. - A sticky mouse trap with a piece of fudge cake was found beside an upright cooler. The AM stated, we have mice in the building, I just put the new sticky traps out this morning with fresh fudge cakes. - A shelf about the stove had small black rodent pellets. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to accurately complete the Minimal Data Set (MDS) assessment for dialysis services for one (1) of one (1) resident reviewed for the care area of dialysis, and for one (1) of one (1) resident reviewed for the care area of discharge, during the long term care survey. Resident Identifiers: #5 and #62. Census 65. Findings Included: a) Resident #5 On 03/06/23 an electronic record review found the quarterly MDS, with an Assessment Reference Date (ARD) of 02/09/23, section O, letter J, Dialysis was marked No, indicating the resident did not receive dialysis. The electronic record contained a physician's order for dialysis dated March 2021. On 03/06/23 at 1:05 PM, the resident said he has been receiving dialysis for years, including February of 2023. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre admission Screening And Resident Review (PASARR) for a resident with a newly evident or possible serious mental disorder for one (1) of four (4) residents reviewed for the category of PASARR, during the long term care survey. Resident identifier #5. Census 65. Findings Included: a) Resident #5 On 03/07/23 the Director of Nursing (DON) was asked to provide the most recent PASARR for Resident #5. The DON presented a PASARR for resident #5, dated 09/10/10. The review of this PASARR, section III MI/MR (Mental Illness / Mental Retardation) Assessment, #30 Current Diagnosis, letter n. Other related conditions (Specify:), was answered, Adjustment Disorder. All other choices on this section were not checked. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and staff interview, the facility failed to provide pressure ulcer care and treatments consistent with the professional standards of care for one (1) of one (1) resident reviewed for the care area of pressure ulcers during the long term care survey process. Resident identifier: #1. Facility census: 65.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation and staff interview the facility failed to provide catheter care with current professional standards of practice. This was true for one (1) of one (1) resident reviewed for catheter care. Resident identifier: #4. Facility census 65.
- B
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This has the potential to affect more than a limited number of residents residing at the facility. This was a random opportunity for discovery. Facility census: 65.
Fire safety inspections
20 fire safety citations on file: 5 on September 10, 2025, 11 on July 11, 2024, 4 on March 8, 2023.
Every fire safety citation20 citations
- C
Install corridor and hallway doors that block smoke.
K 363 · September 10, 2025 · Corrected (the home has a date of correction)
- C
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 10, 2025 · Corrected (the home has a date of correction)
- C
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 10, 2025 · Corrected (the home has a date of correction)
- C
Have properly installed electrical wiring and gas equipment.
K 511 · September 10, 2025 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 10, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 11, 2024 · 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 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 11, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 8, 2023 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 8, 2023 · Corrected (the home has a date of correction)
- C
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 8, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 8, 2023 · Corrected (the home has a date of correction)