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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
2E
1F
Potential for minimal harm
0A
0B
0C
March 5, 2026Standard inspection, Complaint inspection · 4 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to ensure staff honored residents' rights related to self-determination, which affected 1 (Resident #31) of 1 resident reviewed for dignity concerns.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 (Resident #31) of 1 resident reviewed for abuse. Specifically, CNA #18 failed to report an allegation of staff-to-resident abuse that occurred on 09/06/2024 until 09/13/2024.
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on record review, interview, review of facility policy, and review of the American Heart Association Adult Basic Life Support Algorithm, the facility failed to have documented evidence that Emergency Medical Services (EMS or 911) was contacted or that an Automated External Defibrillator (AED) was utilized when cardiopulmonary resuscitation (CPR) was provided for 1 resident (Resident #78) of 2 residents reviewed for CPR, who had a physician's order for a full code (a medical directive indicating that if a person's heart stops or they stop breathing, healthcare providers will use all available life saving measures to revive them).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to activate a resident's physician orders for blood glucose monitoring and sliding scale insulin that were listed in the medication administration software queue, which caused staff to not monitor blood glucose levels or provide insulin according to the order. The deficiencies affected 1 (Resident # 78) of 2 residents reviewed for diabetes management. The facility implemented corrective actions to correct the identified deficient practice from [DATE] to [DATE], to include a change in electronic health record software, staff training, and ongoing audits; thus, past noncompliance was cited.
March 23, 2022Standard inspection · 8 citations
- E
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 facility policy review, medical record review, and interview, the facility failed to perform Interdisciplinary Team (IDT) Care Plan meetings for 10 of 29 sampled residents (Resident #2, #3, #9, #12, #17, #21, #22, #28, #29, and #43) and the facility failed to revise the Care Plan for 1 of 29 sampled residents (Resident #2).
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on facility documentation and interview the facility failed to have at least 8 hours of Registered Nurse (RN) coverage in the facility.
- 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 facility policy review, medical record review, and interview, the facility failed to notify family of a change of condition for 1 of 29 sampled residents (Resident #2) related to a significant weight loss.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to maintain privacy for 4 of 29 sampled residents (Resident #9, #11, #12, and #17) related to swallowing difficulties. Review of the facility's undated policy, titled, Notice of Privacy Practices, revealed, .Our Responsibilities .Maintain the privacy of your health information . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Dysphagia, Oropharyngeal phase. Review of Resident #9's Physician Order dated 6/23/2021 and 6/28/2021 revealed, .ST (Speech Therapy) eval [evaluate] and treat as indicated .SLP (Speech Language Pathologist) to treat for dysphagia to increase swallow safety skills and symbolic language treatment to increase to communication/cognition for ADLs [Activities of Daily Living] safety, as indicated . [...]
- 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 facility policy review, medical record review, and interview, the facility failed to implement a care plan for 1 of 29 sampled residents (Resident #29) reviewed for care plans.
- 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 facility policy review, medical record review, observation, and interview, the facility failed to store medications and biologicals appropriately for 4 of 29 sampled residents (Resident #10, Resident #33, Resident #47, and Resident #304) reviewed receiving medications and biologicals.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on facility documentation, medical record review, observation and interview the facility failed to serve a therapeutic diet during the lunch meal for 1 of 29 sampled residents (Resident #12) observed.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observations, and interview, the facility failed to maintain dietary equipment in a sanitary manner in the dietary department during 1 of 3 observations.
April 16, 2019Standard inspection · 1 citation
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of the facility policy, review of the manufacturer's recommendation, observation, interview and review of the Dishware/Warewashing Machine Temperature Log, the facility failed to operate the dish machine wash cycle within the recommended minimum 160 degrees Fahrenheit (F) in 1 of 6 observations.
Fire safety inspections
16 fire safety citations on file: 6 on March 5, 2026, 1 on March 23, 2022, 9 on April 16, 2019.
Every fire safety citation16 citations
- D
Establish staff and initial training requirements.
E 37 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · March 5, 2026 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 23, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 16, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 16, 2019 · 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 16, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 16, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 16, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 16, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 16, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 16, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 16, 2019 · Corrected (the home has a date of correction)