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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
1F
Potential for minimal harm
0A
1B
0C
April 15, 2026Standard inspection · 0 citations
March 12, 2025Standard inspection · 1 citation
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and staff interview, 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 3 of federal fiscal year (FY) 2024 (April 1 through June 30, 2024). This failure occurred for 1 of 4 quarters reviewed.
January 10, 2024Standard inspection · 5 citations
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on Medical Director, Psychiatrist, Director of Nursing, and Consultant Pharmacist interviews, and record reviews, the facility failed to identify the need to clarify a physician's medication order for crushing Bupropion HCl SR (a sustained release antidepressant) for 1 of 6 residents reviewed for significant medication errors (Resident #65). This resulted in Resident #65 receiving 11 crushed doses of the medication over a 6-day period.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record reviews, observations, and staff resident interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Residents #64).
- D
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 observations, record review and staff interviews, the facility failed to discard expired medications in 1 of 1 medication storage room (Juniper Hall Med Storage Room).
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and interviews with the resident, the resident's representative and staff, the facility failed to educate and offer the COVID-19 vaccine on admission and failed to maintain a resident's record of COVID-19 vaccine history. This was for 1 of 5 residents reviewed for immunizations (Resident #2).
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of Hospice for Resident #7 and #5. This was for 2 of 8 residents reviewed for MDS accuracy.
Fire safety inspections
12 fire safety citations on file: 7 on April 15, 2026, 2 on March 12, 2025, 3 on January 10, 2024.
Every fire safety citation12 citations
- E
Have properly located and lighted "Exit" signs.
K 293 · April 15, 2026 · deficient, provider has
- E
Provide properly protected cooking facilities.
K 324 · April 15, 2026 · deficient, provider has
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 15, 2026 · deficient, provider has
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 15, 2026 · deficient, provider has
- 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 · April 15, 2026 · deficient, provider has
- D
Install an approved automatic sprinkler system.
K 351 · April 15, 2026 · deficient, provider has
- D
Have proper medical gas storage and administration areas.
K 923 · April 15, 2026 · deficient, provider has
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 12, 2025 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Establish an Emergency Preparedness Program (EP).
E 1 · January 10, 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 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 10, 2024 · Corrected (the home has a date of correction)