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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
7D
1E
2F
Potential for minimal harm
0A
0B
1C
May 28, 2026Complaint inspection · 3 citations
- G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on facility policy review, medical record review, video surveillance footage review and interview, the facility failed to provide individualized behavioral interventions, and sufficient supervision to prevent wandering, and exit seeking behaviors, for 1 resident (Resident #1) of 4 residents reviewed for behaviors which resulted in actual Harm to Resident #1. The facility's failure to provide sufficient monitoring, supervision, and adequate care plan interventions in response to wandering and exit seeking behaviors, resulted in Resident #1 sustaining fall related injuries during a wandering episode on 4/28/2026.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on review of the facility policy, observation, and interview, the facility failed to remove resident plates and utensils from serving trays, to promote a dignified dining experience for 8 of 8 residents observed in the [NAME] 1 dining room and delayed assistance to 1 dependent resident (Resident #13) for 20 minutes who was seated at the same table as other residents received and finished their meals.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the facility abuse policy, review of facility investigations, and interviews, the facility failed to ensure facility reported incidents (FRI) related to allegations of abuse were reported within a timely manner for 4 residents (Residents #1, # 2 #3 and #4) of 11 residents sampled for abuse or neglect.
February 27, 2024Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, medical record review, review of the facility investigation, observation, and interviews, the facility failed to prevent abuse for 1 resident, (Resident #2) of 7 residents reviewed for abuse or neglect. The facility's failure to prevent abuse with subsequent injuries of Resident #2 after an assault by Resident #3, resulted in actual Harm of Resident #2. F 600 was cited at a Harm as past non-compliance. The facility is not required to submit additional corrective actions.
November 2, 2022Standard inspection · 4 citations
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of medical record reviews, and interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for 1 resident (Resident #8) and the facility completed a 5-day MDS assessment for 1 resident (Resident #62) after discharged from the facility of 20 residents reviewed for MDS assessments.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper storage of oxygen cylinders (tanks) (metal container filled with compressed gas and held under high pressure) in 1 resident's room (Resident #10) of 9 residents reviewed for oxygen usage.
- 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 hospice contract review, medical record review, and interview, the facility failed to ensure timely and collaborative communication between the hospice provider and the facility for 1 resident (Resident #24) of 6 residents reviewed for hospice services.
- C
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on Centers for Medicare and Medicaid (CMS) guidelines, facility policy review, facility COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccination documentation, and interview, the facility failed to ensure COVID-19 vaccination medical exemption documentation included all required components for 2 of 3 staff with medical exemptions for the COVID-19 vaccination.
December 18, 2019Standard inspection · 0 citations
October 31, 2018Standard 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 facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen free from undated, unlabeled foods, or opened to air food items in 2 coolers; and free from dirt and debris in 1 ice cream freezer, 1 walk in cooler, 1 of 3 steam tables, and on 1 dish in the kitchen, potentially affecting 149 of 151 residents.
- F
Keep all essential equipment working safely.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to maintain 1 of 3 three compartment steam tables in safe operating condition in 1 of 1 kitchens potentially affecting 149 of 151 residents.
- D
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Inspectors wroteBased on review of the facility admission packet, medical record review, review of trust transaction history, observation, and interview, the facility charged the personal fund account for incontinence care items for 1 resident (#72) of 34 incontinent residents reviewed of 44 sampled residents.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on medical record review and interview, the facility failed to obtain consent and notify the resident representative of changes to the psychiatric drug regimen of 1 resident (#82) of 5 residents reviewed for unnecessary medications of 44 residents sampled.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to refer to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review), after the resident was identified with a possible serious mental disorder, for 1 resident (#112) of 7 residents reviewed for PASARR.
Fire safety inspections
13 fire safety citations on file: 4 on November 2, 2022, 6 on December 18, 2019, 3 on October 31, 2018.
Every fire safety citation13 citations
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 2, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 2, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · November 2, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 2, 2022 · Corrected (the home has a date of correction)
- F
Construct fire resistant interior walls.
K 331 · December 18, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 18, 2019 · Corrected (the home has a date of correction)
- D
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 · December 18, 2019 · 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 · December 18, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · December 18, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 18, 2019 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 31, 2018 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 31, 2018 · Corrected (the home has a date of correction)
- C
Establish an Emergency Preparedness Program (EP).
E 1 · October 31, 2018 · Corrected (the home has a date of correction)