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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
0E
1F
Potential for minimal harm
0A
0B
0C
April 30, 2026Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations and interviews, the facility failed to ensure the safe storage of oxygen cylinders in 1 (West 1) of 4 units observed.
May 2, 2024Standard inspection, Complaint inspection · 2 citations
- 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 observations, interviews, and facility document review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 2 (Residents #42 and #75) of 2 residents reviewed for medication storage.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on record review and interview, the facility failed to ensure training was appropriate and effective as determined by staff need, following an incident resulting in 1 (Resident #19) sustaining a burn from over-heated food.
January 12, 2023Standard inspection · 4 citations
- D
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 observation, and staff interviews, the facility failed to store a urinary catheter drainage bag in a sanitary manner to prevent infection for 1 (Resident #117) of 3 residents sampled with indwelling catheters.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide oxygen therapy as ordered to meet the needs of 1 (Resident #82) of 2 residents reviewed for oxygen administration.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, policy review, staff and resident interviews, the facility failed to ensure 2 (Resident #58, and #141) of 6 residents observed with siderails were assessed for alternative interventions prior to the use of the siderails and informed consent explaining the risks and benefits was obtained prior to installation of the bedrails. The facility failed to have documentation of routine maintenance of the bed rails to ensure they remained safe for residents' use.
- 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 and interviews the facility failed to ensure the medication cart remained secured when not in direct view of the nurse for 1 (5100 hall Medication cart) of 9 medication carts.
May 27, 2021Standard inspection · 2 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 maintain food preparation equipment in a clean and sanitary manner; failed to ensure food is maintained at a safe internal temperature; failed to maintain a minimum wash temperature in the dishwasher to ensure effective sanitization of dinnerware.
- 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 and interview, the facility failed to ensure medications were secured, locked and inaccessible to unauthorized staff, residents, and visitors, or under direct observation of authorized staff by 1 (LPN Staff A) of 4 staff observed administering medications. The facility also failed to remove expired medications from active supply for 1 (Memory care) of 3 medication carts observed and failed to document the opened date of a multi-dose vial of medication for 1 (Second floor medication room) of 2 medication storage rooms observed.
Fire safety inspections
9 fire safety citations on file: 7 on May 2, 2024, 1 on January 12, 2023, 1 on May 27, 2021.
Every fire safety citation9 citations
- F
Conduct testing and exercise requirements.
E 39 · May 2, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 2, 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 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 2, 2024 · Corrected (the home has a date of correction)
- E
Have proper power supply for life support equipment.
K 915 · May 2, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 2, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · January 12, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 27, 2021 · Corrected (the home has a date of correction)