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 7 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
1F
Potential for minimal harm
0A
0B
0C
February 4, 2026Standard inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for two (Residents #96 and #154) of three residents reviewed for oxygen therapy. Neither resident was receiving oxygen at the flow rate ordered by their physicians.
March 28, 2024Standard inspection, Complaint inspection · 4 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure the residents' right to personal privacy and confidentiality of personal and medical records when facility forms and documents were left unsecured on the top of three (300 hall, 600 hall, and 700 hall) out of six medication carts and taped to the top of one (600 hall) of two nursing stations' counters where passersby could see them.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that residents who required respiratory care received such care consistent with professional standards of practice for three (Residents #110, #146, and #150) of 25 residents who required oxygen therapy from a total sample of 50 residents. failed to ensure that physicians' orders for respiratory care were followed as prescribed, and when not followed, the reasons were recorded in the residents' medical record during that shift for three (Residents #110, #146, and #150) of 25 residents requiring oxygen therapy, from a total sample of 50 residents.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one (Resident #26) of 50 residents in the total sample, was free from any physical restraints imposed for purposes other than the resident's medical condition. Inappropriate use of restraints could result in injury, skin breakdown, asphyxia, and/or strangulation among other things.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to 1) Use appropriate alternatives prior to installing a siderail. 2) Review the risks and benefits of siderails with the resident or resident representative and obtain informed consent prior to installation, and 3) Re-assess the resident for risk of entrapment from siderails for one (Resident #26) of a total of 50 residents sampled.
September 8, 2023Complaint 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 observations, staff interviews, and review of facility records, the facility failed to maintain kitchen food distribution carts in a clean, safe, and sanitary manner for 3 of 5 food carts observed during lunch service to resident rooms. Failure to provide food services that meet standards of professional food service safety place residents at risk for possible illness.
March 31, 2022Standard inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure the medical records were accurately documented in accordance with acceptable standards of practice for one (Resident #81) of two residents reviewed for respiratory care; and for one (Resident #91) of one resident reviewed for skin care, from a total of 23 residents in the sample.
Fire safety inspections
6 fire safety citations on file: 2 on February 4, 2026, 4 on March 28, 2024.
Every fire safety citation6 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 4, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 4, 2026 · Corrected (the home has a date of correction)
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 28, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 300 · March 28, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · March 28, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 28, 2024 · Corrected (the home has a date of correction)