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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
0E
1F
Potential for minimal harm
0A
0B
0C
January 16, 2026Standard inspection · 9 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure preventive measures were in place to prevent developing of new skin impairment and deterioration of current pressure ulcer, and failed to follow physician orders in wound management. These failures affect one (R144) residents in the sample of 31 reviewed for Pressure Ulcer/Wound Care Management, and resulted in R144 all developing a Stage 3 Sacral Pressure ulcer, with R144's wound needing debridement.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow management of waste bins. This deficiency has the potential to affect all 156 residents receiving food from the kitchen. Findings Include:On 1/13/2026 at 9:38 AM during kitchen initial round, one garbage bin with more than half full of refuse was without a lid/cover. Garbage bin was by food preparation area and there was no staff currently working in the vicinity of immediate area. V5 (Food Service Director) stated if there is no staff currently working in the area, garbage bins should have the lid on. On 1/13/2026 at 10:14 AM, V1 (Administrator) stated he is not sure of the policy for garbage bins management in the kitchen. V1 said he is not sure if garbage bin should have a lid when not in use. [...]
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assure resident's personal privacy for electronic medical records and during administration of insulin. This deficiency affects two (R85 and R132) of three residents in the sample of 31 reviewed for Resident Privacy.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a PASSAR (Pre-admission Screening and Resident Review) level 2 screening for evaluation and determination of newly evident serious mental illness related condition and prescribed medication, for one of one resident (R108) reviewed for a PASSAR level 2 screening in a sample of 31. Findings Include. On 1/15/2026 at 10:30am, R108's admission record documented a new Diagnosis, dated 5/12/2025, for Delusional Disorder, and on 12/20/2025 for Major Depressive Disorder, with added medication of Venlafaxine HCI 75 mg one time per day for Depression. On 1/15/2026 at 10:45am, V1 (Administrator) said, I know that residents with a mental illness should have a PASSAR level 2 completed but not if they have dementia. [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 2 of 3 residents (R12, R45) reviewed for PASARR in a total sample of 31. Findings Include:
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions and follow the recommendation of Occupational Therapy for residents with limited mobility. This affects two (R1 and R124) of three residents in the sample of 31 reviewed for Restorative Program.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement oxygen equipment storage affecting 1 of 2 (R118) residents reviewed for oxygen administration in a sample of 31. Findings Include:On 1/13/2026 at 11:04 AM, R118's oxygen nasal cannula tubing was on top of the bed, without a visible date, tubing touching the floor, and not currently in use. V21 (Certified Nursing Assistant) said she was not sure if tubing should be stored in a bag when not in use but stated would loop tubing and placed on top of the concentrator. V21 then looped the tubing and placed on top of oxygen concentrator. On 1/13/2026 at 11:24 AM, V10 (Registered Nurse) stated R118 uses her oxygen as needed and when not in used, tubing should be stored in a (plastic) bag for infection control purposes. [...]
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its hospice services agreement in provision of information for coordinated hospice care. This deficiency affects one (R87) of three residents in the sample of 31 reviewed for Hospice Care Management.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during medication administration. This deficiency affects all three (R49, R50 and R85) residents in the sample of 31 reviewed for Infection control prevention program.
February 27, 2025Standard inspection · 0 citations
April 18, 2024Standard inspection · 0 citations
Fire safety inspections
23 fire safety citations on file: 9 on January 16, 2026, 10 on February 27, 2025, 4 on April 18, 2024.
Every fire safety citation23 citations
- F
Use approved construction type or materials.
K 161 · January 16, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 16, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 16, 2026 · deficient, provider has
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 16, 2026 · Corrected (the home has a date of correction)
- E
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · January 16, 2026 · 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 · January 16, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · January 16, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 16, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 16, 2026 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 27, 2025 · 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 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 27, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 27, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 18, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 18, 2024 · Corrected (the home has a date of correction)