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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
6E
2F
Potential for minimal harm
0A
0B
0C
February 5, 2026Complaint inspection · 2 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to protect the resident's right to be free from misappropriation of property for 1 (Resident #1) of 3 residents reviewed.
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on observation, record review and interview, the facility failed to protect the right to be free from involuntary seclusion for 1 (Resident #2) or 4 residents reviewed.
August 19, 2025Complaint inspection · 1 citation
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, review of facility policy, resident and staff interviews, the facility failed to provide the necessary care and services for personal hygiene and incontinent care for 2 (Resident #100 and #2) of 3 residents reviewed for activities of daily living.
February 20, 2025Standard inspection, Complaint inspection · 10 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 interviews, and record reviews, the facility failed to follow proper sanitation and cleaning practices in the kitchen to prevent the outbreak of foodborne illness.
- 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, record review, residents and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for 9 (Rooms #238, #240, #243, Residents #75's room, #103's room, #109's room, and #81's room)of 22 residents' rooms observed, and 2 (Unit 2A and 2B) of 2 shower rooms observed.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 8 (Residents #109, #346, #196, #108, #138, #103, #9, and #65) of 9 residents dependent upon staff for care received the necessary care and assistance for activities of daily living.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 2 (Residents #6 and #123) of 3 sampled residents received care in accordance with the established plan of care.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to ensure licensed nurses followed infection prevention practices during blood glucose monitoring for 2 (Residents #447 and #131) of 2 residents observed. The facility failed to ensure urinary catheter drainage bags were stored in a safe and sanitary manner for 2 (Residents #103 and #75) of 2 residents observed with urinary catheter drainage bags stored on the floor.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and interview, the facility failed to ensure that resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine and that the resident's medical record includes documentation that the resident or resident representative were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, documentation of COVID-19 vaccine administered to the resident; or documentation the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for 5 (Residents #97, #67, #133, #104, #108 ) of 5 residents reviewed for vaccinations.
- 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 resident and staff interviews, the facility failed to support the resident's right to voice a grievance without fear of discrimination or reprisal for 1(Resident #103) of 2 residents reviewed for grievances.
- 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 interview and record review, the facility failed to develop a care plan to meet the needs of 1 (Resident #51) of 4 residents reviewed for comprehensive care plan.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, clinical record review, review of facility Standards and Guidelines, resident and staff interviews, the facility failed to ensure proper storage of medication for 2 (Residents #107 and #81) of 2 residents observed with unsecured over the counter medications at bedside and 1 (Unit 1A) of 3 units observed with medication left unsecured and unattended.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review, resident, resident representative and staff interviews, the facility failed to allow 1 (Resident #18) of 2 residents reviewed the right to participate in their care by failing to inform the resident and representative in advance of the discontinuation of a medication.
September 18, 2024Complaint inspection · 1 citation
- D
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 provide maintenance services to maintain a clean and comfortable environment in 1 (Memory Care) of 3 units observed.
August 11, 2022Standard inspection · 4 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, and staff interview, the facility failed to provide a clean, and sanitary environment in the kitchen by not having clean walls, air conditioning vents, food appliances, food preparation, and storage areas. The facility also failed to properly store food, clean, and make necessary repairs in 2 (nourishment rooms 1B and 2B) of 2 nourishment rooms observed. This failure had the potential to cause food borne illness in residents receiving an oral diet.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure implementation of a person centered, meaningful activity program for 1 (Resident #72) of 7 residents reviewed for activities.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, review of facility policy and staff interviews, the facility failed to remove and discard expired medications from 2 (Memory Care and 2B) of 4 medication carts, and 1 (medication storage room [ROOM NUMBER]A) of 2 medication storage rooms observed. This has the potential for expired medications to be administered to residents.
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review the facility failed to have a designated qualified Infection Preventionist with the education, training, experience or certification.
February 11, 2021Standard inspection · 0 citations
Fire safety inspections
17 fire safety citations on file: 3 on February 20, 2025, 6 on August 11, 2022, 8 on February 11, 2021.
Every fire safety citation17 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · February 20, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 20, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 11, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 11, 2022 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 11, 2022 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 11, 2022 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 11, 2021 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 11, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 11, 2021 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 11, 2021 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 11, 2021 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · February 11, 2021 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · February 11, 2021 · Corrected (the home has a date of correction)
- D
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 · February 11, 2021 · Corrected (the home has a date of correction)