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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
2F
Potential for minimal harm
0A
0B
0C
February 26, 2026Standard inspection · 1 citation
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to inform residents of the risks, benefits, and alternative treatment options prior to initiating new psychotropic medications. This affected one resident (#7) out of five reviewed for unnecessary medications. The facility census was 47.
May 2, 2024Standard inspection · 3 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, record review, interview and review of facility policy, the facility failed to ensure food was served in a sanitary manner. This had the potential to affect all 52 residents in the facility, as the facility identified all 52 residents received meals from the kitchen. The facility census was 52.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review, staff interview and policy review the facility failed to ensure peripherally inserted central catheters (PICC) were flushed appropriately and as ordered by the physician. This affected one (Resident #113) of five residents reviewed for medications. The facility identified three residents (102, 103 and 113) with current PICC line or intravenous (IV) lines for medication administration. The facility census was 52.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, medical record review, review of manufacturer's instructions and staff interview the facility failed to ensure respiratory equipment including continuous positive airway pressure (CPAP) equipment were properly cleaned per manufacturer's instructions. This affected one resident (Resident #9) of three residents reviewed for respiratory equipment use. The facility census was 52.
June 26, 2023Standard inspection · 6 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, staff interview, and review of the facility policy the facility failed to ensure all food was labeled, dated, and discarded properly. The facility identified all residents received food from the kitchen, which had the potential to affect all 49 residents.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview, record review, and review of Baseline Care Plan facility policy revealed the facility did not ensure baseline care plans were implemented and/ or that the resident and/ or resident representative received a copy of the baseline care plan within 48 hours of admission that included goals, objectives, and interventions of the residents' current needs. This affected four residents (#56, #161, #165, and #170) out of 26 residents reviewed for care plans. The facility census was 49. 1. Review of medical record for Resident #165 revealed an admission date of [DATE] and she was discharged on [DATE]. Her diagnoses included moderate protein-calorie malnutrition, abnormal involuntary movements, restlessness, agitation, and difficulty walking. No baseline care plan was noted in her medical record that included goals, objectives, and interventions of her current needs. [...]
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review, interview, and facility policy review the facility failed to ensure a resident's wish regarding end-of-life measures was clearly identified in the medical record. This affected one (Resident #39) of 24 residents screened for Advanced Directives.
- D
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 medical record review, interview, and facility policy review the facility failed to revise care plans for two residents (#15 and #16) of 27 residents whose care plans were reviewed. The facility census was 49.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, record review, and review of weight policy revealed the facility did not ensure weights were obtained as ordered by the physician and/ or per facility policy. This affected two residents (#161 and #164) out of four residents reviewed for nutrition. The facility census was 49.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview, observation, record review, and facility policy review the facility did not ensure Resident #167 had an order for oxygen and had appropriate signage indicating oxygen was in use on her door. This affected one resident (#167) out of two residents reviewed for respiratory therapy. This had the potential to affect eight residents (#13, #15, #21, #164, #167, #171, #173, and #258) receiving oxygen.
Fire safety inspections
9 fire safety citations on file: 2 on February 26, 2026, 6 on May 2, 2024, 1 on June 26, 2023.
Every fire safety citation9 citations
- E
Provide properly protected cooking facilities.
K 324 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 2, 2024 · 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 · May 2, 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 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 26, 2023 · Corrected (the home has a date of correction)