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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
0E
0F
Potential for minimal harm
0A
0B
0C
March 9, 2026Standard inspection · 3 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure they reported to the Department of Health (DOH) as required, an allegation of resident- to- resident abuse. Resident #5 had behavior of being aggressive toward staff and other residents. According to the clinical notes dated 8/2/25, Resident #5 threw a shoe at another resident who was sitting in the living room of the facility. The other resident was not identified and the incident was not reported. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #5) and was evidenced by the following:On 3/4/26 at 9:20 AM, the surveyor observed the resident exited a room with multiple stuffed animals and dolls in their hands. At 10:30 AM, that same day, a Certified Nursing Aide (CAN) identified the resident as Resident #5. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to investigate an allegation of potential resident to resident abuse by a resident who displayed aggressive behaviors toward staff and other residents, when on 8/2/25 Resident #5 threw a shoe at another resident who was sitting in the living room of the facility. This deficient practice was identified for 1 of 3 residents reviewed for incident/accidents and was evidenced by the following: On 3/4/26 at 9:20 AM, the surveyor observed Resident #5 independently ambulating and was exiting another resident's room. Resident #5 was also observed holding multiple stuffed animals and dolls in their hands. [...]
- 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 observation, interview, record review and review of other facility documentation, it was determined that the facility failed to have a process in place to ensure that consistent communication between the facility and the hospice provider occurred for the coordination of resident care. This deficient practice was identified for one 1 of 1 resident reviewed for hospice care (Resident #35) and the deficient practice was evidenced by the following:On 3/4/26 at 10:09 AM, the surveyor observed Resident #35 seated in a recliner and was non-verbal. The surveyor then reviewed the electronic and paper medical record for Resident #35. According to the Face sheet, an admission summary, Resident #35 was admitted to the facility with diagnoses which included but were not limited to; [...]
September 12, 2024Standard inspection · 1 citation
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all eligible residents were educated and offered the pneumococcal vaccination (vaccine) to prevent incidence of pneumonia. The deficient practice was identified for 2 of 5 residents reviewed for immunizations (Resident #23 and Resident #40), and was evidenced by the following: 1. On 9/8/24 at 10:44 AM, during initial tour of the facility, the surveyor observed Resident #40 in the activity room sleeping upright in their wheelchair. On 9/9/24 at 10:27 AM, the surveyor reviewed the medical record for Resident #40. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses included but not limited to; dementia, major depressive disorder, and generalized weakness. [...]
August 31, 2023Standard inspection · 2 citations
- 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 observation, interview, record review and review of facility policy, it was determined that the facility failed to ensure the facility policy was followed to identify and adequately monitor target behaviors for residents receiving psychoactive drug therapy for 2 of 2 residents (Residents #27 and #33) reviewed for use of psychoactive medication use. The deficient practice was evidenced by the following: 1. On 08/22/23 at 10:05 AM during the initial tour, the surveyor observed Resident #27 sitting in the room and a visitor was at the bedside. The surveyor knocked on the door and was prompted by the visitor to enter the room. The surveyor explained the purpose of the visit to both the resident and the visitor. The visitor identified himself as the resident's representative and agreed to engage in a conversation with the surveyor at a later time. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review it was determined that the facility failed to follow their Handwashing/Hand Hygiene policy and perform hand hygiene during a lunch meal observation. This deficient practice was observed on 1 of 2 resident units and was evidenced by the following: On 08/22/23 at 11:55 AM, during the observation of the lunch meal in the main dining area on the fourth-floor unit, a Certified Nurse Aide (CNA) #1 was observed without performing hand hygiene as follows: 11:55 AM before and after delivering a lunch tray to Resident #1. 11:59 AM before and after delivering a lunch tray to Resident #2. 12:04 PM before delivering a lunch tray to Resident #3, and then required a second tray and was taken away. 12:07 PM CNA # 1 reached into her scrub top pocket, answered her cell phone, put the phone back into her pocket and then delivered a tray to Resident #3. [...]
Fire safety inspections
22 fire safety citations on file: 7 on March 9, 2026, 8 on September 12, 2024, 7 on August 31, 2023.
Every fire safety citation22 citations
- 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 9, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · March 9, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 9, 2026 · Corrected (the home has a date of correction)
- F
Install properly constructed windows in hallway walls or doors.
K 364 · March 9, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 9, 2026 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · March 9, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 9, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 12, 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 · September 12, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 12, 2024 · 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 12, 2024 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 31, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 31, 2023 · 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 · August 31, 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 · August 31, 2023 · Corrected (the home has a date of correction)