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 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
2E
1F
Potential for minimal harm
0A
0B
0C
April 16, 2026Standard inspection · 4 citations
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on the review of the Quality Assurance Performance Improvement (QAPI) sign in sheets, staff interview and policy review, the facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 28 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, staff interviews and observation the facility failed to provide professional standards of care by administering medications for 1 of 12 residents reviewed (Resident #4). The facility reported a census of 30 residents.
- 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 resident, staff interviews and record review, the facility failed to provide a restorative program to a resident with mobility concerns for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 30 residents.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on clinical record review, staff interview, Centers for Disease Control and Prevention (CDC) guidelines the facility failed to screen for eligibility, offer, provide education, and document vaccine consent or refusal for the pneumococcal immunizations for 3 of 5 resident reviewed (Residents #6, #22, and #27) for immunizations. The facility reported a census of 30 residents.
October 8, 2025Complaint inspection · 2 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents were free from abuse for 2 of 3 residents reviewed (Resident #2 and #3) by another resident (Resident #1). Resident #1 touched Resident #2 inappropriately on the chest on 2 separate occasions, and Resident #3 on 1 occasion. The facility reported a census of 27 residents.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents and/or their representatives had the right choose a pharmacy for 1 of 3 resident's reviewed (Resident #4). The facility reported a census of 27 residents.
March 20, 2025Standard inspection · 4 citations
- 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 record review and staff interview, the facility failed to provide to the resident and the resident representative, written notice of the bed hold policy when on hospital leave, which specified the duration of the bed-hold policy and reserve payment, for 3 of 3 residents reviewed (Resident #8, #11, and #2). The facility reported a census of 26 residents.
- 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 record review and staff interview, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents reviewed for psychotropic medications (Resident #21). The facility reported a census of 26 residents.
- 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 observation, record review, and staff interview, the facility failed to ensure a resident's care plan was reviewed and revised after each assessment for 2 of 11 residents reviewed (Resident #8 and #14). The facility reported a census of 26 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident who needed Oxygen (O2) had documentation when they received oxygen for 1 of 2 residents reviewed (Resident #11). The facility reported a census of 26 residents.
March 21, 2024Standard inspection · 5 citations
- F
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on personnel file review, interviews, and review of the Direct Care Worker (DCW) Registry the facility failed to verify and assure a student certified nursing assistant (CNA) actually became certified and registered after completing the CNA course and taken the written exam for 1 of 5 CNAs reviewed (Staff G). The facility reported a census of 30 residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on clinical record review, staff interviews and review of Medicare guidelines, the facility failed to provide a notice of Medicare Non-coverage 48 hours in advance of services ending for 1 of 3 residents reviewed (Resident #2). The facility also failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form for 2 of 2 residents (Resident #2 and #6) whose skilled stay ended and continued to reside in the facility. The facility reported a census of 30 residents.
- 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 clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by resident and or the resident's responsible person when residents transferred out of the facility for 2 of 4 residents reviewed (Residents #4 and #35). The facility reported a census of 30 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, infection control policy, and staff interview, the facility failed to use personal protective equipment (PPE) and perform hand hygiene when exchanging water pitchers for residents suspected of having the Norovirus for rooms 208, 209 and 213. The facility reported a census of 30 residents.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on personnel file reviews, facility policy review and staff interview, the facility failed to provide the required 2 hour dependent adult abuse training within 6 months of hire for 2 of 9 employees reviewed (Staff D and E). The facility identified a census of 30 residents.
Fire safety inspections
10 fire safety citations on file: 2 on April 16, 2026, 2 on March 20, 2025, 6 on March 21, 2024.
Every fire safety citation10 citations
- F
Establish policies and procedures for volunteers.
E 24 · April 16, 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 · April 16, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 21, 2024 · 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 21, 2024 · 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 21, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 21, 2024 · Corrected (the home has a date of correction)
- D
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 · March 21, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 21, 2024 · Corrected (the home has a date of correction)