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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
26D
3E
1F
Potential for minimal harm
0A
0B
0C
June 18, 2026Standard inspection, Complaint inspection · 13 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the facility's water management plan, facility documentation, and staff interviews, it was determined that the facility failed to implement control measures in the cooling tower and closed loop systems as the water management plan indicated to prevent the growth of Legionella bacteria, and the facility failed to conduct remedial control measures timely and appropriately for eight of ten months (November 2025 to March 2026). Findings Include: Review of the facility's Water Management Plan dated 3/15/25, revealed for this water management plan to be most effective, it must be fully implemented. The persons responsible for verifying implementation of control measure are listed within each control measure. Cooling tower systems (CTs) present the potential for Legionella growth and exposure and are identified as a significant risk and control location. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) of non-coverage forms and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R67).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on a review of clinical records, facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to implement abuse prevention and investigation procedures for one of four residents reviewed (Resident R79) following an allegation of possible misappropriation of medication and medical neglect as defined as the facility policy.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, facility documents, facility submitted documentation, and staff interviews, it was determined that the facility failed to report allegations of possible misappropriation of medication and medical abuse as defined by the facility policy for one of three sampled resident records (Resident R79).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff and resident interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of three residents (Resident R79).
- 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 review of facility provided documents, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of a resident with mental health needs for one of three residents (Resident R20) and with a pacemaker transmitter for one of four residents (Resident R23).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a physician order for bowel protocol for two of six residents (Resident R39, R75).
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to meet residents pain needs for one of six residents reviewed (Resident R1). Findings Include: Review of the facility policy Pain Assessment Management Record Procedure dated 8/28/25, indicated the facility is committed to the promotion of the resident comfort through the assessment and effective management of resident pain. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of multiple rib fractures, pneumonia and pain. Review of Resident R1's care plan dated 5/26/26, revealed the resident was experience pain or the resident was at risk for pain and discomfort. Interventions included to administer pain medications as ordered, observe for side effects and effectiveness. [...]
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record review, and staff interview it was determined that the facility failed to develop and implement an individualized person - centered care plan to address dementia for a resident with a diagnosis of dementia for one of three residents (Resident R20).
- 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication storage rooms (Redwood Medication Room).
- 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 a review of resident clinical records, facility policy, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R44).
- D
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to one of five direct care facility staff reviewed (Nurse Aide (NA) Employee E19).
- D
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 review of job description, facility documents and staff interviews, it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year for one out of two Nurse Aide (NA) Employees (Employee E19).
March 13, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, clinical records, investigation documents, and other resources, as well as staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that a resident was free from accident/hazards by failing to provide a second person to assist with a stand-up lift transfer, which resulted in harm as evidenced by a displaced fractured humerus (upper arm bone), hospitalization, and functional loss of right hand for one of three residents reviewed (Resident 1).
July 31, 2025Standard inspection · 12 citations
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for three of four residents (Resident R11, R17, and R41).
- E
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 review of facility policy, observations and staff interviews, it was determined that the facility failed to properly store medical supplies in two of three medication rooms (Maple Place and [NAME] Court), and on two of three medication carts (Birch Place and [NAME] Court).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for one of three residents (Resident R6).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a review of facility documents, clinical record, and staff interviews, it was determined that the facility failed to ensure a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form were provided in a timely manner for two of three residents (Resident R32 and CR Resident R333).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of five resident hospital transfers (Residents R4, and R8).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order for two of five residents (Resident R18 and R19), and failed to follow the bowel protocol in a timely fashion for one of five residents (Resident R17).
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on review of clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of three residents (Resident R17 and R77).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R77).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of six residents (Resident R17 and R35).
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for one of three residents (Resident R14).
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (Quarter One of 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) policy dated 8/8/24, indicated it is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a medication pass for one of three residents (Resident R6), failed to prevent cross contamination and follow enhanced barrier precaution during a dressing change for one of three residents (Resident R7) and failed to properly monitor residents in room personal refrigerator temperatures for four of five residents (Resident R1, R34, R35, and R67) which created the potential for food borne illness.
August 1, 2024Standard inspection · 5 citations
- E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on review of facility policies, in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective annual in-service training program for four of of eight personnel records (Nurse Aide Employee E3, Nurse Aide Employee E4, Nurse Aide Employee E5, and Nurse Aide Employee E6).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, clinical records, facility provided documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of abuse for one of two residents (Resident R31).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse for one of two residents (Resident R31).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of two resident (Residents R17).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R25).
Fire safety inspections
13 fire safety citations on file: 5 on June 18, 2026, 4 on July 31, 2025, 4 on August 1, 2024.
Every fire safety citation13 citations
- 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 · June 18, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 18, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 18, 2026 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · June 18, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 18, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · July 31, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 31, 2025 · 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 · July 31, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 31, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · August 1, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 1, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 1, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · August 1, 2024 · Corrected (the home has a date of correction)