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
7D
3E
0F
Potential for minimal harm
0A
0B
1C
April 17, 2026Standard inspection · 4 citations
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to be able to file a grievance anonymously and failed to post information on how to file a grievance, in accordance with the facility's grievance policy. The sample was 12. The census was 83 with 44 residents in certified beds. Review of the facility's admission Agreement, undated, showed:-A list of key personnel included the name, title, phone extension, and email of Administrative staff;-A staff person shall be designated to receive grievances, and the residents shall be free to voice their recommendations and complaints to that person, an ombudsman or any person outside the facility. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff utilized appropriate techniques during two-person Hoyer lift (mechanical lift) transfers to prevent potential accidents for four residents (Residents #23, #36, #34, and #14). The sample was 12. The census was 83 with 44 residents in certified beds.1. Review of Resident #23's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 4/2/26, showed-Severe cognitive impairment;-Diagnoses included generalized muscle weakness, other abnormalities of gait and mobility, and syncope and collapse (fainting and falling);-Totally dependent on assistance with transfers, with two or more staff;-Utilized wheelchair for mobility. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, precautions for use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms (MDROs, microorganisms that are resistant to one or more classes of antimicrobial agents) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) when staff failed to wear a gown while providing direct care for two residents (Residents #5 and #1). The sample was 12. The census was 83 with 44 residents in certified beds. [...]
- C
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the contact information for the State Survey Agency and for the State Long-Term Care (LTC) Ombudsman were prominently posted in a form and manner that was accessible to all residents and resident representatives. The sample was 12. The census was 83 with 44 residents in certified beds. Review of the facility's Resident Rights policy, revised December 2025, showed the resident has the right to communicate with outside agencies (e.g., local, State, or Federal officials, State and Federal surveyors, State Long-Term Care Ombudsman, protection and advocacy organizations, etc.) regarding any matter. Observations of the receptionist desk throughout the duration of survey, from 4/13/26 through 4/17/26, showed six plastic display holders containing various pieces of literature. [...]
June 12, 2024Standard inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not reporting timely after an allegation of sexual abuse was made by one resident (Resident #12) of 12 sampled residents. The census was 82 with 46 in certified beds. Review of the facility's Freedom from Abuse, Neglect and Exploitation-Investigation and Reporting policy, revised November 2023, showed: -Policy Statement: At the facility, all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Reporting: All alleged violations involving abuse will be reported to the facility Administrator. Or his/her designee, to the following persons or agencies: [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to ensure they followed their abuse policy by failing to conduct a thorough investigation into one resident's (Resident #12) allegation of sexual abuse. The resident reported the incident to a family member on 1/20/24. The facility initiated an investigation but failed to interview other residents regarding the incident of abuse. The sample size was 12. The census was 82 with 46 in certified beds. Review of the facility's Freedom from Abuse, Neglect and Exploitation-Investigation and Reporting policy, revised November 2023, showed: -Policy Statement: At the facility, all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; [...]
November 16, 2022Standard inspection · 5 citations
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were encoded and transmitted timely for 4 (Residents #1, #5, #277, and #478) of 11 sampled residents whose MDS assessments were reviewed for timeliness of submission.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure staff members wore face coverings in three of four common resident areas when the community transmission of COVID-19 was high.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed not less than every three months for 2 (Resident #177 and Resident #478) of 11 sampled residents whose MDS assessments were reviewed for timeliness of completion.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide treatment and care in accordance with professional standards for wound care related to a skin tear for 1 (Resident #476) of 2 sampled residents reviewed for skin conditions. Review of physician's orders revealed no order for the wound care and observations revealed Resident #476 had a skin tear with a dressing that had been in place for five days.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure kitchen staff wore beard guards to prevent potential contamination of food prepared in one of one kitchen.
Fire safety inspections
14 fire safety citations on file: 6 on April 17, 2026, 3 on June 12, 2024, 5 on November 16, 2022.
Every fire safety citation14 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 12, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · June 12, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 16, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 16, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 16, 2022 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 16, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 16, 2022 · Corrected (the home has a date of correction)