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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
8E
0F
Potential for minimal harm
0A
0B
0C
June 25, 2026Standard inspection · 2 citations
- E
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, interview, and record review, the facility failed to provide a homelike environment, by serving residents' meals on serving trays in an institutional manner, for all residents who ate meals in the dining area on the secured unit for three different meals observed.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 46 residents, (#199).
August 22, 2024Standard inspection · 11 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, interview, and record review, the facility failed to secure one (1) treatment cart to prevent unauthorized access and promote resident safety, (Riverside), and failed to properly store medications and bottles of liquids in four (4) medication carts and one (1) treatment cart, (Bayside, Oceanside, and Riverside), for 6 of 8 carts inspected during the Medication Storage task, of a total of 14 medication/treatment carts.
- 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 and interview, the facility failed to ensure food items were stored in a manner to prevent contamination by keeping them sealed, dated and discarded before their expiration date. This failure had the potential to negatively effect 158 of 158 residents who consumed food items by mouth.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to Activities of Daily Living (ADLs) for Dependent Residents and Activities to Meet Resident Interest or Needs.
- 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 record review, the facility staff failed to treat residents with dignity and respect as evidenced by addressing them as, feeders, and not allowing a resident's choice to ambulate freely while waiting for meals, for 4 of 17 residents on the locked memory care unit, (#104, #94, #122 and #61).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prohibition policy and procedures related to an allegation of mistreatment by 1 of 2 residents reviewed for abuse, of a total sample of 51 residents, (#146).
- 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 observation, interview, and record review, the facility failed to implement the comprehensive care plan related to interventions to prevent falls and injuries for 1 of 5 residents reviewed for accidents, of a total sample of 51 residents, (#51).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care related to personal hygiene for 1 of 1 resident reviewed for ADLs, of a total sample of 51 residents, (#146).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized activities program was provided for 1 of 2 residents reviewed for Activities, of a total sample of 51 residents, (#156).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered as ordered by the physician, in accordance with professional standards, for 2 of 3 residents reviewed for respiratory care, of a total sample of 51 residents, (#57 and #77).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications according to physician orders to prevent medication errors for 2 of 5 residents reviewed during the Medication Administration task, of a total sample of 51 residents, (#33 & #62). There were 4 errors in 29 opportunities for a medication error rate of 13%.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices during distribution of lunch trays and set up of lunch meals on 1 of 2 hallways, (400 hallway), on 1 of 4 units, (Riverside Unit).
November 3, 2022Standard inspection · 10 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided for 3 of 6 dependent residents, (#1, #4, #119) and failed to ensure facial hair was removed for 1 of 6 dependent residents, (#479) reviewed for Activities of Daily Living (ADL) out of a total sample of 62 residents.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the preferences and needs for 6 of 12 residents reviewed for activities of a total sample of 62 residents, (#10,#21,#51,#118,#137,#139).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for splint application for 2 of 2 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143).
- E
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview, and record review, the facility failed to provide Occupational Therapy as needed to address splint application and assessments for 3 of 3 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143, #175).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview, and record review, the facility failed to complete Minimum Data Set (MDS) assessments within required timeframes for 3 of 4 residents reviewed for MDS comprehensive assessments from a total sample of 62 residents, (#60, #123, #154).
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview, and record review, the facility failed to electronically transmit Minimum Data Set (MDS) assessments timely for 2 of 4 residents reviewed for MDS assessments, from a total sample of 62 residents, (#105, #123).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for life expectancy for 1 of 5 residents reviewed for unnecessary medications, (#81) and failed to accurately reflect the discharge status for 1 of 3 residents reviewed for discharges, (#176), of a total sample of 62 residents.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive care plan for activities within seven days after completion of the comprehensive assessment for 1 of 12 residents reviewed for activities, of a total sample of 62 residents, (#81) .
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide nutritional supplements ordered for a newly admitted resident diagnosed with moderate protein malnutrition for 1 of 1 resident reviewed for nutritional status in a total sample of 62 residents, (#479).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate transmission-based precautions (TBP) for Extended Spectrum Beta-Lactamase (ESBL) for 1 of 2 residents (#115) reviewed for Urinary Track Infection (UTI) and failed to ensure an indwelling urinary catheter drainage bag was not placed on the floor to prevent infection for 1 of 2 residents reviewed for indwelling urinary catheter (#130) out of a total sample of 62 residents.
Fire safety inspections
5 fire safety citations on file: 1 on June 25, 2026, 4 on November 3, 2022.
Every fire safety citation5 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 25, 2026 · Corrected (the home has a date of correction)
- E
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 · November 3, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 3, 2022 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · November 3, 2022 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 3, 2022 · Corrected (the home has a date of correction)