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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
3E
1F
Potential for minimal harm
0A
0B
0C
June 29, 2026Complaint inspection · 1 citation
- 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 and document review the facility failed to review and revise a care plan for 1 of 3 residents (R1) whose care plan was reviewed for revisions.
June 6, 2025Complaint 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 observation, interview and document review the facility failed to ensure adequate supervision and scheduled toileting to reduce the risk for falls for 1 of 3 residents (R1) who had a history of falls. This resulted in actual harm for R1 who had an unwitnessed fall requiring emergency department (ED) services, sustained a laceration to the head, received five staples, and was admitted to the hospital for further observation. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance.
May 1, 2025Complaint 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 interview and record review, the facility failed to immediately consult with the resident's physician for a need to alter treatment significantly for one of one resident (R1) reviewed. This practice resulted in a delay of treatment to R1's pressure ulcers.
April 16, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and document review, the facility failed to use proper personal protective equipment (PPE) who are on enhanced barrier precautions (EBPs) for 1 of 3 (R1) residents reviewed for falls.
September 12, 2024Standard inspection · 8 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 observation, interview and document review the facility failed to ensure food was properly disposed of after their best by dates in 2 of 4 serving kitchens and failed to ensure food was properly stored in 2 of 4 of the serving kitchens reviewed. This had the potential to impact residents who reside on the unit the serving kitchen is located.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate transmission-based precautions (TBP) were used for 3 of 3 residents (R69, R108, R4) who had COVID-19. Furthermore, the facility failed to ensure proper hand hygiene was used for 1 of 1 residents (R72) observed during personal care.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and document review, the facility failed to report to the state agency (SA) allegations of potential neglect and verbal abuse for 2 of 3 residents (R30, R37).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure R30 received a pillow for positioning for prevention of pressure ulcers and that aided in comfort associate with contractures.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure supplemental oxygen was properly maintained per professional standards for 1 of 1 resident (R30).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on inteview and document review the facility failed to identify potential triggers and offer specialized services for 1 of 1 resident (R275) who had a history of trauma.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide medication as ordered by the provider for 1 of 3 residents (R72) observed during medication administration.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and document review the facility failed to ensure medication errors were prevented for 2 of 4 residents (R72, R109) observed during medication administration. This resulted in a medication error rate of 7.69%.
August 30, 2023Standard inspection · 10 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, interview, and document review, the facility failed to ensure foods were labeled, free from freezer burn, and the freezers were cleaned and maintained. Additionally, the facility failed to ensure use of hair restraints during food preparation and the refrigerators in the unit dining rooms were maintained.
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide air bed monitoring for safety and function for 1 or 1 resident (R6), reviewed for air bed safety.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R6, R8) reviewed for dignity.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 2 of 2 residents (R25, R98) had been assessed to safely self-administer medications.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide interpreter services for 1 of 1 resident (R98) with a preferred language of Cantonese reviewed for communication.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide privacy for 1 of 1 resident (R98), when a topical medication was administered. R98's annual Minimum Data Set (MDS) dated [DATE], lacked indication of a R98's cognitive status with Care Area Assessment (CAA) triggered for cognitive loss, dementia and communication. R98 required extensive assist of one staff for bed mobiity, and personal hygiene. [...]
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and document review, the facility failed to initiate a grievance process to address family member (FM) concerns pertaining to level of care changes for 1 of 2 residents (R5) reviewed for grievances.
- 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, interview, and record review, the facility failed to ensure appropriate management of an indwelling catheter was provided for 2 of 2 resident (R31, R6) reviewed for indwelling catheters.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and document review, the facility failed to monitor side effects for 1 of 3 (R43) residents reviewed for anticoagulation (blood thinner) therapy.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure hand hygiene was completed during catheter cares and catheter cares were provided to minimize risk of infection for2 of 2 residents (R31, R6) observed for indwelling catheters. Furthermore, the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R20) observed for incontinent cares.
March 10, 2022Standard inspection · 0 citations
Fire safety inspections
8 fire safety citations on file: 3 on September 12, 2024, 3 on August 30, 2023, 2 on March 10, 2022.
Every fire safety citation8 citations
- F
Install an approved automatic sprinkler system.
K 351 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · September 12, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 30, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 30, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 30, 2023 · Corrected (the home has a date of correction)
- C
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · March 10, 2022 · Corrected (the home has a date of correction)
- C
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 10, 2022 · Corrected (the home has a date of correction)