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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
3E
6F
Potential for minimal harm
0A
0B
0C
July 30, 2026Complaint inspection · 1 citation
- D
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 observations, staff and resident interviews, record review, review of the facility's policy titled Notification of Changes, and Your Rights and Protections as a Nursing Home Resident, the facility failed to notify the emergency contact and/or responsible party after a fall for two of 11 sampled residents (R) (R1 and R2). This deficient practice had the potential to compromise the residents' rights to have their representatives informed of significant changes in condition and to participate in decisions regarding the residents' care and treatment.
February 19, 2026Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to prevent sexual abuse by another resident for one of three residents (R) (R2 and R1) reviewed. This failure allowed R1 to continue to potentially sexually abuse other residents after his behavior of getting in bed with other residents was first identified.
October 2, 2025Standard inspection · 15 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observations, interviews, record review, document review and review of the facility policy titled, the facility failed to provide sufficient staff to meet the residents' needs timely. This failure to provide Activities of Daily Living (ADL) care, assistance with dressing and transported to the dining room for meals, timely incontinence care, program of activities, services to prevent further decrease in range of motion/mobility for a resident with contracture had the potential to negatively impact quality of life for all residents.
- 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, interview, and review of the facility policy titled, the facility failed to ensure refrigerated foods in the walk-in cooler were stored and labeled correctly and dish wear stored under the air conditioner [NAME] were covered and the dish wear inverted. This deficient practice had the potential to affect 107 of 111 residents who received meals prepared in the facility's only kitchen.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, interviews, record review and facility policy, Administration failed to ensure residents' environment on two of four halls (200, and 400) was clean, in good repair and homelike. Administration failed to ensure residents (R33 and R14) were free from sexual and physical abuse. Administration failed to ensure allegations of sexual abuse were thoroughly investigated for R33 and reported timely to the State Survey Agency (SSA) (R14 and R12). Administration failed to ensure residents (R53, R59, R12 and R2) care plans were developed for activities with interventions for residents that required diversional activities, activities in their rooms and activities that were appropriate for residents with dementia on the secure unit. Administration failed to ensure residents were provided with activities to meet their needs (R53, R60, R74 and R97). [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on interview and review of the facility policy titled, Equipment the facility to maintain the ice machine and primary oven in working order. Specifically, the ice machine did not provide the ice needed to meet the needs of the residents and family members had to buy ice for the residents, and the primary range oven did not work and could not be used. This deficient practice had the potential to affect 107 of 111 residents who received meals prepared in the facility's only kitchen.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, interview, and review of the facility policy titled, Activities the facility failed to provide, based on the comprehensive assessment and care plan and the preferences, a program of activities to support residents in their choice of activities for four of four residents (Resident (R)53, R60, R74, and R97) in the sample of 31 residents and failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being of residents in the facility. This failure had the potential to negatively impact quality of life for the affected residents.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure two of 31 Residents (R)(R39 and R41) were treated with dignity and respect. Specifically, the facility failed to ensure R39 was provided with incontinence care when requested and allowed to remain in a soiled brief for over two hours, the facility also failed to ensure R41 was able to have visitation in her room that was free from offensive odors.
- 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 observations, interviews and review of the facility policy titled, Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on two of four halls (200 and 400) in the facility. This failure could negatively impact resident due to not having a sanitary, homelike living environment.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews, record review and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure two of four residents (R) (R33 and R14) were free from abuse; R33 from sexual abuse by R57 and R14 from physical abuse by R2.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews, record reviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report allegations of resident-to-resident abuse to the State Survey Agency (SSA) within the two hours once the facility was aware of the abuse allegation for two of four residents, Resident (R) (R14 and R12). The failure of the facility to report these incidents timely has the likelihood to lead to future unreported allegations of resident abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on resident record reviews, interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate an alleged allegation of sexual abuse for one of one resident (R) (R33) and physical abuse for one of one resident (R14) in the sample of 31 residents. The failure by the facility to failure to thoroughly investigate allegations of abuse had the potential to negatively impact residents in the facility.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, record review, and review of the facility policies titled, Transfer and Discharge, and Bed Hold Policy, the facility failed to ensure for two of two Resident (R) (R59 and R74) and Resident Representative (RR) received a written notice of transfer, and a written bed hold notice that included all the required information. In addition, the facility failed to ensure the Long-Term Care Ombudsman was notified of R59 and R74's hospital transfers.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Resident Assessment- RAI, the facility failed to ensure the comprehensive assessment accurately reflected Pre-admission Screening and Resident Review (PASSR) level II for one (Resident (R) 1) of two residents reviewed for PASSR level II and to ensure the comprehensive assessment accurately reflected contractures for one resident (R59) of one resident reviewed for contractures in the sample of 31 residents. R1's annual Minimum Data Set (MDS) assessment failed to document PASSAR level II. This failure had the potential to lead to a lack of services. R59's quarterly MDS assessment failed to document limited range of motion in upper extremity. [...]
- 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, record review and review of the facility policy titled, Comprehensive Care Plans , the facility failed to develop a comprehensive care plan for four of 31 Resident (R) (R53, R59, R12 and R2). This failure placed the resident at risk for unmet care needs, and the inability to meet their maximum practicable level of functioning.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, record review and review of the facility policy titled, Activities of Daily Living (ADL), the facility failed to provide timely incontinence care for two of three Residents (R) (R39 and R8) reviewed for Activities of Daily Living (ADL) in the sample of 31 residents. The facility's failure could negatively impact residents' overall feelings of wellbeing, and their willingness to socialize or participate in activities and other residents and/or staff.
- 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 observation, interviews, and record review, the facility failed to ensure residents admitted to the facility with a contracture were provided with the services to prevent further decrease in range of motion/mobility for one of two Resident (R) (R59).
May 30, 2024Standard inspection · 6 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on staff and family interviews, and review of facility documents titled, Facility Assessment Tool 2024 and the PBJ (payroll-based journal) Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023), the facility failed to ensure that the facility had adequate nursing staff. The deficient practice had the potential to affect the care provided to the 116 residents that resided in the facility.
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Menus, the facility failed to serve the meal listed on the cycled menu for residents who received an oral diet from the kitchen. Specifically, the cycled menu stated ham and California vegetable blend was to be served for dinner, but instead, a sloppy joe was served. The deficient practice affected 115 of 116 residents who received an oral diet from the kitchen.
- 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 observations, staff interviews, and review of the facility policy titled, Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment in nine of 53 resident rooms on two of four halls, and in the lobby media common area. Specifically, these rooms and halls contained pests (flies), damaged floor fall strips, dirty wall sheetrock, dirty privacy curtain with missing hanging hooks, stained, brown, and damaged floor tiles, damaged bathroom toilet commodes, damaged baseboard, dirty, broken packaged terminal air conditioner (PTAC) unit vent covers, damaged soap dispensers, and crowded furniture (beds with crank adjustment) in the lobby media common area. Review of the facility policy titled Resident Environmental Quality dated 2/1/2022 indicated under Policy: [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Resident Smoking, the facility failed to enforce its smoking policy adequately for one of 23 sampled residents (R) (R68) reviewed for smoking compliance. Specifically, this failure allowed R68 to vape unsupervised in his room. The deficient practice had the potential to cause safety issues, including fire.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Administration of Dry Powder Inhalers and Peripherally Inserted Central Catheter Flushing, Locking, Removal, the facility failed to ensure that residents were free of medication administration errors of more than 5 percent (%) for two of 41 sampled residents (R) (R36 and R111). Specifically, one of three nurses observed failed to have R36 rinse their mouth after administration of an inhaler, and one of three nurses observed failed to properly disinfect the lumen (inside space) of the peripherally inserted central catheter (PICC) line of R111.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Peripherally Inserted Central Catheter Flushing, Locking, Removal, the facility failed to use proper infection control practice when flushing a needleless connector of a peripherally inserted central catheter (PICC) for one of three Residents (R) (R111) observed during medication administration. The deficient practice had the potential to cause infection for R111.
December 21, 2022Standard inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Dietary Employee Personal Hygiene and Staff Attire, the facility failed to ensure food was prepared, distributed, and served in accordance with professional standards for food service quality. Specifically, the facility failed to ensure four of six staff members observed (Dietary Manager (DM), Kitchen Staff (1), Kitchen Staff (2), and the Social Services Director (SSD) had their hair restrained appropriately which had the potential to affect all residents on an oral diet. Facility census was 108 with 107 residents recieiving an oral diet.
Fire safety inspections
24 fire safety citations on file: 6 on October 2, 2025, 8 on May 30, 2024, 10 on December 21, 2022.
Every fire safety citation24 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 2, 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 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Provide rooms that can be unlocked from inside without a key.
K 221 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 2, 2025 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · May 30, 2024 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · May 30, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 30, 2024 · Corrected (the home has a date of correction)
- D
Have an enclosure around a vertical opening shaft.
K 311 · May 30, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 30, 2024 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 30, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 30, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 30, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 21, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 21, 2022 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · December 21, 2022 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · December 21, 2022 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · December 21, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 21, 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 · December 21, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 21, 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 · December 21, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 21, 2022 · Corrected (the home has a date of correction)