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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
2D
3E
1F
Potential for minimal harm
0A
0B
0C
June 4, 2026Standard 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 observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and one out of one satellite kitchen. Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated, and discarded within appropriate good-through timeframes.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on record review and interview, the facility failed to ensure residents' rights regarding arbitration were protected for three (#28, #36 and #39) of three residents reviewed for arbitration out of a sample size of 27. Specifically, the facility failed to inform the Resident #28, Resident #36, Resident #39 or their representative that they had the right to rescind or terminate the agreement within 30 calendar days of signing.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training to ensure continued competence for five of five CNAs reviewed. Specifically, the facility failed to have a system in place to ensure CNAs including CNA #5, CNA #8, CNA #9, CNA #10 and CNA #11 received annual dementia training.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of five residents reviewed for accidents out of 27 sample residents. Specifically, the facility failed to ensure:-Resident #4, who had a pressure ulcer, had physician's orders for the settings on his air mattress; and, -Ensure staff regularly checked on the functioning of Resident #4's air mattress.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for two (#52 and #3) of five residents out of 27 sample residents. Specifically, the facility failed to:-Ensure to maintain, clean, sanitize and properly store Resident #52's bilevel positive airway pressure (BiPAP) machine (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) and mask;- Ensure Resident #3's CPAP (continuous positive airway pressure) therapy was provided per physician's orders; and,-Ensure Resident #3 had a physician's order specifying the oxygen flow rate.
April 16, 2024Standard inspection · 1 citation
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#31) of three residents reviewed for pressure-related skin conditions out of 19 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #31, who was at risk for developing pressure injuries due to a recent surgery to replace his left hip joint, was admitted to the facility on [DATE]. According to the facility's assessment of the resident's skin on 3/8/24, the resident was admitted without any pressure injuries. The facility implemented a pressure reducing mattress upon the resident's admission, however, there were no interventions implemented for offloading the resident's heels, which were at an increased risk for skin breakdown due to the resident's decrease in mobility following the left hip surgery. [...]
January 10, 2023Standard inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteIII. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia, abnormalities of gait and mobility, difficulty in walking, and lack of coordination. The 11/20/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. He required one-person extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. He required two-person extensive assistance for dressing. The Fall History on Admission/Entry or Reentry section of the MDS assessment was not completed. B. Observations On 1/4/23 at 1:27 p.m., Resident #26 was lying in bed with his eyes closed. There was a thick padded fall mat on the floor beside the bed. [...]
- E
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 record review and interviews, the facility failed to inform the physician and/or the resident's legal representative in a timely manner that the residents had a fall in the facility for two (#26 and #54) of six residents reviewed for falls out of 17 sample residents. Specifically, the facility failed to: -Ensure Resident #26's physician was notified on one occasion following the resident sustaining a fall in the facility; -Ensure the legal representative for Resident #26 was notified in a timely manner on six different occasions following the resident sustaining falls in the facility; and, -Ensure the legal representative for Resident #54 was notified in a timely manner on two different occasions following the resident sustaining falls in the facility.
Fire safety inspections
14 fire safety citations on file: 1 on June 4, 2026, 8 on April 16, 2024, 5 on January 10, 2023.
Every fire safety citation14 citations
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 16, 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 · April 16, 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 · April 16, 2024 · Corrected (the home has a date of correction)
- E
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 · April 16, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 16, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 16, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 16, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 10, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2023 · Waiver
- F
Have simulated fire drills held at unexpected times.
K 712 · January 10, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 10, 2023 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 10, 2023 · Corrected (the home has a date of correction)