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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
2K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
1E
0F
Potential for minimal harm
0A
0B
0C
August 21, 2025Standard inspection · 0 citations
July 11, 2024Standard inspection, Complaint inspection · 4 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure residents were assessed to determine their capacity to consent or were free from sexual abuse for three of 24 sampled (Residents (R) 2, R33, and R34). Review of facility documentation of multiple incidents and sexual abuse allegations involving R63 revealed the following: 1. On 02/22/2022, staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident. The facility failed to assess the residents for their ability to consent and failed to update R63's care plan related to the monitoring that occurred after the event. 2. [...]
- K
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's policy, it was determined the facility failed to ensure its staff developed and implemented the resident's care plan with interventions to address inappropriate sexual behavior and failed to ensure the residents were assessed and care planned for the ability to consent to sexual activity for four of 24 sampled residents (Residents (R) 63, R2, R33, and R34). On 02/22/2022, Resident (R) 63 was observed by staff to have kissed R2. The facility failed to develop R63's comprehensive care plan to address the inappropriate behavior. Then approximately 6 months later, on 08/14/2022, R63 kissed R2 again, after R2 asked for a kiss. The facility considered this incident mutual, however, when the facility interviewed R2 after the incident, she could not recall the incident. [...]
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of any significant medication errors for one of seven sampled residents (Residents (R)58). On 05/03/2022, R58 developed increased altered mental status and was sent to the emergency room (ER) for evaluation. During assessment of R58 at the ER, the ER nurse discovered a 75 microgram (mcg) fentanyl patch (narcotic medication used to treat severe pain) on the resident's left upper arm/shoulder. However, review of the facility's information for R58 revealed no documentation noting fentanyl as one of R58's medications. Review of R2's (R58's roommate) orders revealed that resident had an active order for a 75 mcg fentanyl patch. The Director of Nursing (DON) assessed R2 and did not find the resident's prescribed fentanyl patch. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect one (1) out of ten (10) sampled Residents (R), R43. Observation revealed R43's room door had a sign posted noting the resident was on Enhanced Barrier Precautions (EBP). However, further observation revealed Certified Nurse Aide (CNA) 3 entered R43's room without donning Personal Protective Equipment (PPE) as required.
May 14, 2021Standard inspection · 2 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure food was served at an appetizing temperature. Resident interviews and review of Resident Council Meeting minutes revealed resident complaints of cold food. Observation of the tray line on 05/11/2021 revealed the facility was not using the pellet warmer (part of the plate warming system to keep food warm). A test tray was obtained on 05/11/2021, and the mixed greens were cool and not at an appetizing temperature.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBase on observation, interview and record review the facility failed to keep food stored under sanitary condition. A dented can of apples was stored on a shelf in the kitchen available for use.
Fire safety inspections
10 fire safety citations on file: 3 on August 21, 2025, 3 on July 11, 2024, 4 on May 14, 2021.
Every fire safety citation10 citations
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 21, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · August 21, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 11, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 11, 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 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · May 14, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 14, 2021 · 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 · May 14, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 14, 2021 · Corrected (the home has a date of correction)