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
9D
1E
0F
Potential for minimal harm
0A
0B
0C
July 14, 2026Complaint inspection · 3 citations
- 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 record review and staff interviews during a survey, the facility failed to ensure a comprehensive person-centered care plan develop and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one out of four residents (Resident #1) sampled. Specifically, a comprehensive care plan was not developed with interventions for use of diuretic medication and Resident #1's diagnoses.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and staff interviews, during a survey the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for one out of four residents (Resident #1) sampled. Specifically, Resident # 1 was given 14 milligrams of Hydrochlorothiazide (diuretic) at once at 10:00 AM on 06/04/2026, instead of 7 milligrams. Registered Nurse #1 did not follow the physician's order for Hydrochlorothiazide 7 milligrams every 12 hours.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, record review and staff interviews during a survey, the facility failed to ensure the physician write, sign, and date a telephone order. This was evident for one out of four residents (Resident #1). Specifically, Resident #1 was administered Tylenol suppository 240 milligrams rectally on 05/15/2026 at 9:30 PM. Resident #1 was transferred to the emergency room on [DATE] to be evaluated for Tylenol toxicity. Resident #1 returned to facility same day with no interventions recommended. Attending Physician #1 did not write, sign, or date the telephone order received by Registered Nurse #1 on 05/15/2026.
August 28, 2024Standard inspection · 2 citations
- D
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, and interview conducted during the Recertification Survey from 08/21/2024 to 08/28/2024, the facility did not ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. Specifically, 1.) Staff was observed handling resident's food with bare hands. This was evident in 1 (6th Floor) of 6 units during dining observation. 2.) The kitchen walk-in refrigerator contained expired and undated food items.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 08/21/2024 to 08/28/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #90) of 2 residents reviewed for Pressure Ulcer / Injury. Specifically, Enhanced Barrier Precautions were not maintained during wound care.
May 3, 2022Standard inspection · 4 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and interviews conducted during the Recertification survey, the facility did not ensure infection control practices were maintained. This was evident for 1 of 5 units (4th floor), 1 of 3 residents reviewed for Respiratory Care (Resident #179), and 1 of 4 residents reviewed for Infections (Resident #496) out of a sample of 38 residents. Specifically, 1) a Registered Nurse (RN) was observed wearing a surgical mask improperly; 2) there were multiple observations of Resident #179's oxygen tubing on the floor; and 3) Resident #496 was not placed on contact/droplet precautions (CDP) following exposure and positive test for COVID-19.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review, and interview during the Recertification survey, the facility did not ensure a baseline care plan (BCP) was developed within 48 hours of admission. This was evident for 1 of 38 residents reviewed (Resident #8). Specifically, a BCP was not completed for Resident #8 within 48 hours of admission to the facility.
- 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 record review and staff interviews conducted during the Recertification survey, the facility did not ensure the comprehensive care plan was prepared by an interdisciplinary team that includes the resident and the resident's representative for 1 (Resident #137) of 38 sampled residents. Specifically, Resident #137's Comprehensive Care Plan (CCP) was created within 21 days after admission on [DATE], but there was no documented evidence Resident #137 was invited to a care plan meeting until after the care plan was complete. A care plan meeting was not held until 2/3/22.
- 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, record review, and interviews conducted during the Recertification survey, the facility did not ensure that all medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (4th floor). Specifically, 1) a bag of prescribed medications was not stored in a locked compartment; and 2) an expired ampule of Digoxin was found in the emergency medication box.
August 12, 2019Standard inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record reviews and interviews, the facility did not ensure that timely identification and removal of medication to be disposed occurred. Specifically, an expired controlled substance was observed in the narcotic cabinet in the medication room. This was observed during the Medication Storage Task. The facility's undated policy and procedure titled Narcotic Count documented that all controlled substances are not available to other than Licensed Nurses, Pharmacists and Medical personnel designated by the facility. Purpose included to assure controlled drugs are handled, stored and disposed of properly. The finding is: Resident #53 was admitted to the facility on [DATE] with diagnoses that included Dementia, Mononeuropathy Unspecified, Partial Traumatic Amputation and Cellulitis of Left Lower Limb. [...]
Fire safety inspections
24 fire safety citations on file: 2 on August 28, 2024, 16 on May 3, 2022, 6 on August 12, 2019.
Every fire safety citation24 citations
- D
Have properly located and lighted "Exit" signs.
K 293 · August 28, 2024 · 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 28, 2024 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 3, 2022 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · May 3, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 3, 2022 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 3, 2022 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · May 3, 2022 · 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 3, 2022 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · May 3, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · May 3, 2022 · 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 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 3, 2022 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · May 3, 2022 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 12, 2019 · 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 · August 12, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · August 12, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 12, 2019 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · August 12, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 12, 2019 · Corrected (the home has a date of correction)