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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
0E
1F
Potential for minimal harm
0A
0B
0C
May 8, 2026Standard inspection · 0 citations
April 20, 2023Standard inspection · 5 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review and staff interview, the facility failed to coordinate a level II assessment for a resident with a diagnosis of intellectual disabilities as required. This affected one (#316) of two residents reviewed for pre-admission screening and resident review (PASARR) status. The census was 92.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview and record review, the facility failed to timely notify the appropriate state mental health authority when a resident with a level II mental illness had a significant change in condition. This affected one (#51) of four residents reviewed for Preadmission Screening and Resident Review (PASARR). The census was 92.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure residents had ophthalmologist recommendations followed up in a timely manner. This affected one (#54) of two reviewed for ancillary services. The census was 92.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to provide timely nutritional supplements as ordered. This affected one (#305) of two resident reviewed for nutrition. The census was 92.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review, resident and staff interview, and policy review the facility failed to ensure residents who were survivors of trauma were assessed and care planned appropriately to address such trauma to maintain the residents highest practical well being. This affected one (#4) of one resident reviewed for trauma informed care. The census was 92.
September 19, 2019Standard inspection · 11 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, staff interview, and review of facility policy, the facility failed to ensure food was stored properly when staff failed to cover foods stored in the freezer. This had the potential to affect all 95 residents that resided in the facility who consumed food from the kitchen.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents were given an opportunity to formulate advanced directives on admission. The facility further failed to ensure resident's advanced directive wishes were consistent throughout the medical record. This affected two residents (#249 and #55) of 21 residents reviewed for advanced directives. The facility census was 95.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on medical record review, staff interview and review of a facility policy, the facility failed to notify a resident's physician, responsible party and Hospice provider of a change in a wound status and to timely notify a resident's family of a fall. This affected two residents (#13 and #94) of 21 residents reviewed for notification. The facility census was 95.
- 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 medical record review and staff interviews, the facility failed to ensure written notification of the facilities bed hold policy was provided to the resident and representative, at the time of transfer. This affected two residents (#75 and #94) of two reviewed for hospitalizations. The facility census was 95.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review, observations, staff interview, resident interview, and facility policy review, the facility failed to ensure two residents (#13 and #75) of three reviewed for pressure ulcers had treatments and services to promote healing and prevent new ulcers from development. The facility identified nine residents with pressure ulcers. The facility census was 95.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure interventions to prevent injury from falls were in place. The facility further failed to ensure resident's call light system was in resident's reach while in their room. This affected one resident (#13) of three reviewed for falls. The facility census was 95.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure an catheter securement device was used to prevent possible injury from the use of an indwelling urinary catheter. This affected one resident (#249) of two reviewed for urinary catheters. The facility census was 95.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to provide a resident with nutritional interventions as ordered for a significant weight loss. This affected one resident (#75) of two reviewed for nutrition. The facility identified three residents with significant weight loss in the census of 95.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to ensure adequate treatment of one resident (#85) of one for psychosocial well being. The facility census was 95.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, review of hospital discharge records, and staff interview, the facility failed to ensure a resident received ordered medications. This affected one resident (#94) of six reviewed for medications. The facility census was 95.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observations, staff interview, and facility policy review, the facility failed to ensure infection control was maintained during a pressure ulcer dressing change for one resident (#75) of three residents reviewed for infection control. The facility census was 95.
Fire safety inspections
14 fire safety citations on file: 5 on May 8, 2026, 6 on April 20, 2023, 3 on September 19, 2019.
Every fire safety citation14 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 8, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 8, 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 · May 8, 2026 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · May 8, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 8, 2026 · Corrected (the home has a date of correction)
- F
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 · April 20, 2023 · 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 20, 2023 · 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 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 20, 2023 · 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 20, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 19, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 19, 2019 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 19, 2019 · Corrected (the home has a date of correction)