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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
1E
1F
Potential for minimal harm
0A
0B
0C
March 31, 2026Standard inspection · 4 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public. This was evident during the initial kitchen tour of the annual survey.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on a medical record review and interviews, it was determined that the facility staff failed to ensure that residents were seen by an attending provider at least every 60 days. This was evident for 1 (Resident #5) of 1 resident reviewed for hospice care.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that attending physicians reviewed and acted on Irregularities identified by the pharmacist in a timely manner. This was evident for one (Resident #4) of 5 Residents reviewed for unnecessary medications.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to maintain essential equipment in proper operating conditions. This was evident for 2 of 2 pieces of equipment reviewed during the annual survey.
February 19, 2025Standard inspection, Complaint inspection · 15 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to store food in a manner that maintained professional standards of food service safety. This practice had the potential to affect all residents who eat the food prepared in the facility's kitchen.
- 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 observations and interviews, it was determined that the facility staff failed to maintain a homelike environment as evidenced of marring on the wall behinds residents' beds. This deficient practice was evidenced in 3 (Resident #4, #11, #28) of 6 resident rooms entered during the medication administration assessment conducted during the survey.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on the review of a facility reported incident and interviews with staff, it was determined that the facility failed to maintain an environment free of physical restraints. This was evident for 1 (MD00182052) out of 4 facility reported incidents reviewed during the annual and complaint survey. The facility implemented corrective measures following this incident and prior to the start of this Survey. The facilities plan and actions were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 8/15/2022.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of a facility reported incident (FRI) and interview with staff, it was determined that the facility failed to report an injury of unknown origin within 2 hours and submit the results of the investigation within 5 days as required to the Office of Health Care Quality. This was evident for 1 (MD00210330) out of 4 Facility Reported Incidents (FRI's) reviewed during the survey.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to include the resident care plan with the required documentation during a transfer. This was evident for 1 (Resident #35) of 2 residents reviewed for hospitalization.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to notify the ombudsman when a resident was transferred to the hospital, and provide written notification of transfer and to ensure the resident and the responsible representative were provided a copy. This was evident for 2 (Resident #35 and #37) of 2 residents reviewed for hospitalization.
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to document the orientation and preparation of a resident upon a transfer. This was evident for 1 (Resident #35) of 2 residents reviewed for hospitalization.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and medical record review, it was determined the facility staff failed to notify the resident/resident representative in writing of the bed hold policy upon transfer. This was evident for 2 (Resident #35 and #37) of 2 residents reviewed for hospitalization.
- D
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 record review and interview with staff, it was determined that the facility failed to ensure a resident centered care plan had been revised to meet the needs of the resident in response to current interventions. This was evident for 1 (Resident #4) out of 2 residents investigated for communication/sensory during the survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure services provided maintained professional standards of practice regarding resident weights. This was evident for 2 (Resident #7 and #21) of 4 residents reviewed for nutrition.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and interviews, it was determined that the facility staff failed to ensure the staff completed a competency required to care for resident's effectively. This was evident for 1 (Resident #8) of 5 staff records reviewed for training during the Medicare/Medicaid survey.
- D
Post nurse staffing information every day.
Inspectors wroteBased on record review and interviews, it was determined that the facility staff failed to update the staffing sheets on the units after the staffing schedule changed. This was evident for 2 of 2 units in the Long-Term Care Wing.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation and interview it was determined that the facility's pharmacy failed to administer a prescribed supplement with a dosage. This was evident for 1 (Resident #19) of 5 resident medication administration observations during survey.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to ensure a resident received routine dental care. This was evident for 1 of 1 resident (Resident #15) reviewed for dental services during the survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to ensure a resident's medical record included all documentation related to dental treatment, and beneficiary notification documentation was correctly completed. This was evident for 1 (Resident #15) of 1 resident reviewed for dental services, and 2 (Resident #189 and #190) of 3 residents reviewed for beneficiary notification during the survey.
December 9, 2020Standard inspection · 0 citations
Fire safety inspections
13 fire safety citations on file: 9 on March 31, 2026, 4 on February 19, 2025.
Every fire safety citation13 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 31, 2026 · Corrected (the home has a date of correction)
- E
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 · March 31, 2026 · Corrected (the home has a date of correction)
- E
Construct fire resistant interior walls.
K 331 · March 31, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 31, 2026 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · February 19, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 19, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · February 19, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 19, 2025 · Corrected (the home has a date of correction)