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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
3E
0F
Potential for minimal harm
0A
0B
0C
March 25, 2026Standard inspection, Complaint inspection · 5 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on facility policy review, facility report review, and interview, the facility failed to notify the Long-Term Care (LTC) Ombudsman of resident discharges from the facility timely for 152 residents discharged from 9/3/2025-3/25/2026.
- E
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 properly store refrigerated food items, which had the potential to affect 77 out of 85 residents.
- 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 facility policy review, observation, and interview, the facility failed to maintain a clean, comfortable, homelike environment for 2 of 4 units observed for a clean, comfortable, homelike environment. Review of the facility's undated policy titled, Housekeeping Services, revealed thorough scrubbing will be used for all environmental surfaces that are being clean in patient care areas .due to the nature of the ventilator unit .cleaning is to be done daily on each shift from housekeeping, nursing staff, and respiratory therapy .Review of the facility's undated policy titled, Housekeeper Job Description, revealed .clean, wash, sanitize, and/or polish bathroom fixtures. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record reviews, observations, and interviews, the facility failed to ensure Physician's Orders were obtained for ventilator (a machine or device used to support or replace the breathing of a person who has difficulty breathing on their own) use for 1 resident (Resident #1) of 3 residents reviewed for ventilators, and for tracheostomy (a surgically created opening in the front of the neck leading into the windpipe/trachea) use for 2 residents (Residents #8 and #9)) of 3 residents reviewed for tracheostomies, the facility failed to ensure oxygen was administered according to Physician's Orders for 1 resident (Resident #65) of 23 residents reviewed for oxygen therapy, and failed to safely secure portable oxygen tanks in residents' rooms for 2 residents (Residents #88 and #69) of 23 residents reviewed for oxygen therapy.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy reviews, medical record reviews, observations, and interviews, the facility failed to ensure practices to prevent the potential spread of infection were maintained by not following Enhanced Barrier Precautions (EBP) and not adhering to appropriate hand hygiene during respiratory care for 2 residents (Residents #1 and #8) of 4 residents with a ventilator and/or tracheostomy, and during medication administration for 1 resident (Resident #22) of 4 residents observed during medication pass, failed to offer hand hygiene assistance prior to meals for 3 residents (Residents #47, #31, and #66) of 23 residents observed during dining, and failed to secure a urinary catheter bag off the floor for 1 resident (Resident #15) of 10 residents observed for urinary catheters.
November 30, 2022Standard inspection · 3 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 facility policy review, observation, interview, and temperature log review, the facility failed to ensure expired and molded food items were not available for resident use and failed to ensure dry goods were properly stored in 1 of 1 kitchen, and failed to properly store and label food items and maintain a temperature log in 1 of 4 nourishment refrigerators which had the potential to effect 66 of 72 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to complete weekly skin assessments to prevent the development of a skin condition for 1 resident (Resident #230) of 5 residents reviewed for pressure ulcers.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician order for a fluid restriction for 1 resident (Resident #20) of 2 residents reviewed for nutrition.
August 14, 2019Standard inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policy, medical record review, review of facility investigation, observation, and interview, the facility failed to ensure 1 resident (#1) was free from abuse of 3 residents reviewed for abuse of 37 sampled residents.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 resident was free from restraints (#77) of 7 residents reviewed for restraints.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on medical record review and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (#46) of 20 sampled residents.
Fire safety inspections
20 fire safety citations on file: 5 on March 25, 2026, 4 on May 1, 2025, 10 on November 30, 2022, 1 on August 14, 2019.
Every fire safety citation20 citations
- D
Provide properly protected cooking facilities.
K 324 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Construct fire resistant interior walls.
K 331 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 25, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
K 227 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Conform to length requirements for dead end corridors.
K 251 · May 1, 2025 · Corrected (the home has a date of correction)
- D
Provide at least two remote exits on each floor or fire section of the building.
K 252 · May 1, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 30, 2022 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 30, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 30, 2022 · Corrected (the home has a date of correction)
- F
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · November 30, 2022 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 30, 2022 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · November 30, 2022 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 30, 2022 · Corrected (the home has a date of correction)
- D
Develop a communication plan.
E 29 · November 30, 2022 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · November 30, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 14, 2019 · Corrected (the home has a date of correction)