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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
3E
1F
Potential for minimal harm
0A
1B
1C
June 23, 2026Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review and resident and staff interviews, the facility failed to treat Resident #1 with dignity and respect when Nurse #1 engaged in a verbal argument with Resident #1 utilizing profanity and yelling at Resident #1. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #1).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, resident, Pulmonologist Office Receptionist, Nurse Practitioner (NP) and staff interviews the facility failed to ensure a resident attended a scheduled pulmonary follow-up visit with the pulmonologist for 1 of 1 resident reviewed for quality of care (Resident #2).
May 11, 2026Standard inspection, Complaint inspection · 4 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 staff interviews, the facility failed to discard dented canned goods stored for use, failed to dry divided plates prior to stacking, and failed to discard a wet cardboard box of pound cakes covered in frozen condensation. These practices occurred in 1 of 1 walk-in freezer, 1 of 1 dishwashing area, and 1 of 1 dry storage area and had the potential to affect food served to residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and Nurse Practitioner, resident and staff interviews, the facility failed to provide clinical assessment and treatment when a resident first reported that he was burned after he accidentally spilled his cup of hot noodles on himself for 1 of 3 residents reviewed for quality of care (Resident #70).
- 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 observation, record review, and interviews with the Responsible Party (RP), staff, Nurse Practitioner (NP), and hospice staff, the facility failed to ensure effective communication and coordination of care occurred with the hospice provider. On 6/29/25, Resident #101, who was under the care of hospice, fell in his room and was assessed by Nurse #1, assisted back to bed and then sent to the Emergency Department (ED) for evaluation. The hospice on call provider was not notified by facility staff before Emergency Medical Services (EMS) was called. This deficient practice affected 1 of 4 sampled residents reviewed for coordination of hospice services (Resident #101).
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on record review, observations and interviews with residents, Responsible Party, and staff, the facility failed to ensure the call light system was functioning properly for 3 of 27 residents who required assistance for activities of daily living (Resident #5, Resident #19, and Resident #48).
April 24, 2025Standard inspection, Complaint inspection · 8 citations
- 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 observation, record review, and staff interviews, the facility failed to secure an opened bottle of antacid for 1 of 1 Resident (Resident #90) and failed to store 3 unopened eye drops at the proper temperature per manufacturer's instructions for 1 of 4 medication cart (100 halls medication cart) review for medication storage.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interviews with resident and staff, the facility failed to ensure dependent residents could access the light switch located behind the bed for 1 of 1 residents reviewed for accommodation of needs (Resident #157).
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accuracy and consistency of advance directive throughout the medical record for 1 of 1 resident (Resident #62) reviewed for advance directives.
- 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 record review, resident and staff interviews, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 1 resident reviewed for safe, clean, comfortable, homelike environment (Resident #71).
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide podiatry care for 1 of 7 residents (Resident #57) reviewed for activities of daily living.
- D
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 interviews, the facility failed to cover facial hair during food service for 1 of 4 dietary staff observed (Dietary Manager #1). This deficient practice had the potential to affect food served to residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to maintain an accurate and consistent electronic medication administration record (eMAR) for 1 of 1 resident review for documentation accuracy (Resident #152).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement Transmission-Based Precautions (TBP) when two Nurse Aides provided incontinence care for Resident #55 and did not wear a gown for 2 of 5 staff members observed for infection control practices (Nurse Aide #3, Nurse Aide #4).
January 17, 2024Standard inspection · 4 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on staff interview and record review, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for quarter 1 of fiscal year (FY) 2023 (October - December 2023). The failure occurred for 1 of 5 quarters reviewed.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interviews with staff and record review, the facility administration failed to provide effective leadership and oversight when the facility failed to enact their emergency operations plan to notify law enforcement of a missing resident. Resident #86 left the facility for a planned leave of absence but did not return to the facility as planned and did not communicate to the facility the Resident's whereabouts for 12 days. This failure occurred for 1 of 1 sampled residents reviewed.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, staff interviews and record review, the facility failed to post a Daily Staffing Record with the current facility name for 4 days of the survey (1/8/24 - 1/11/24) and failed to document the current facility name and accurate staffing data for 14 of 14 days of nurse staffing data reviewed.
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the medical records contained dental visit notes for 1 of 4 residents reviewed for dental care (Resident #1).
Fire safety inspections
12 fire safety citations on file: 7 on April 24, 2025, 4 on January 17, 2024, 1 on May 19, 2022.
Every fire safety citation12 citations
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · April 24, 2025 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · January 17, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 17, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 17, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 17, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 19, 2022 · Corrected (the home has a date of correction)