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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
2E
0F
Potential for minimal harm
0A
1B
0C
March 5, 2026Standard inspection · 9 citations
- 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 and interviews, the facility failed to provide proper sanitation of dishes and sanitizing towels, maintain access to hot water in the kitchen sinks, maintain sanitary conditions of the ice machine in the kitchen, and maintain sanitary conditions of 1 cooler in a unit pantry. This has the potential to affect 146 of 151 residents who consume food, according to the facility's census.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interviews and record review, the facility failed to maintain residents' dignity by arguing loudly about staff assignments in areas where residents could hear. The facility also failed to treat residents with respect by speaking in a language the residents could not understand and raising their voice at a resident when the call light was used to request care, for 2 of 32 sampled residents reviewed, Resident #32 and Resident #94.
- 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 observation and interview, the facility failed to ensure a clean and sanitary environment on 4 of 6 units (100, 300, 400, and 600) affecting 8 of 32 sampled residents (Residents #46, #22, #104, #50, #73, #2, #159 and #1).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders were followed for 1 of 32 sampled residents, Resident #156, as evidenced by lack of evidence that 'as needed' antihypertensive medication was administered to the resident for medication with blood pressure parameters.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on policy review, observation, interview, and record review, the facility staff failed to ensure access to and the provision of fluids for 2 of 2 sampled residents who showed signs of or complained of thirst. Staff did not maintain fluids within reach of Resident #2, failed to open the resident's milk container to allow her to drink, and failed to ensure fluids were within reach for Resident #104.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to maintain sanitary conditions of the garbage area. This has the potential to affect 151 residents, according to the facilities census.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure complete and accurate medical records for 3 of 32 sampled residents, as evidenced by the failure to ensure there was a signed consent for psychotropic medications for Resident #2 was in the record; failure to discontinue physician orders for side rails and seizure precautions for Resident #109 when no longer needed; and failure to discontinue duplicate PRN (as needed) medication orders for Resident #111.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) as ordered for 2 of 7 sampled residents as evidenced by the failure to ensure an accurate order for EBP for Resident #7, failure to use EBP during care for Resident #7; failure to ensure posting of an EBP sign for Resident #95; and failure to maintain the laundry equipment and ceiling vents in a clean and sanitary condition.
- B
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 resident rights for 3 of 55 sampled residents as evidenced by the failure to clearly communicate the residents right to change their mind at any time within thirty business days about entering into an Arbitration Agreement with the facility for Resident #'s 5, 8 and 71 who all signed the Arbitration Agreement.
September 19, 2024Standard inspection · 2 citations
- 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, interviews and record reviews, the facility failed to provide foods prepared, served, and stored under sanitary conditions and in accordance with professional standards for food safety.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, record and policy review, the facility failed to follow through with request for pain medication for 1 of 3 sampled residents reviewed for pain management, Resident #51.
July 20, 2023Standard inspection · 8 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 interview, the facility failed to follow the care plan related to use of bed and chair alarms, for 1 of 5 sampled residents reviewed for falls. Resident #20 had a history of falls, one of which was an assisted fall to the floor when a Certified Nursing Assistant (CNA) heard the alarm, thus preventing injury.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional services to meet the needs for 2 of 5 sampled residents, Residents #65 and #137. The Registered Dietician (RD) failed to do an accurate quarterly assessment for Resident #65, failed to initiate weekly weights with the identification of a significant weight loss, and failed to follow up with the physician on his recommendation for an appetite stimulant. The RD failed to ensure timely interventions for Resident #137, who had a significant weight loss.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain a physician order for oxygen for 1 of 2 sampled residents reviewed for respiratory care, Resident #61, failed to document oxygen administration, and change of oxygen tubing for 1 of 2 sampled residents observed for respiratory care, Resident #32, and failed to have a respiratory care plan for 2 of 2 sampled residents observed for respiratory care, Residents #32 and #61.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, facility staff failed to follow-up on a pharmacy request for a physician clarification related to an ordered medication for 1 of 38 sampled residents (Resident #206).
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, facility staff failed to follow through with an ordered laboratory test for 1 of 1 sampled resident (Resident #128).
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental services for 1 of 1 sampled resident reviewed for dental services, Resident #40.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate resident food preferences for 3 of 17 cognitively intact sampled residents, Residents #46, #91, #89.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accuracy of records for 2 of 38 sampled residents, Residents #206 and #65.
Fire safety inspections
9 fire safety citations on file: 3 on March 5, 2026, 3 on September 19, 2024, 3 on July 20, 2023.
Every fire safety citation9 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 5, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 5, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2026 · Corrected (the home has a date of correction)
- D
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 · September 19, 2024 · 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 · September 19, 2024 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · September 19, 2024 · 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 20, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 20, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 20, 2023 · Corrected (the home has a date of correction)