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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
3E
0F
Potential for minimal harm
0A
1B
0C
March 2, 2026Standard inspection, Complaint inspection · 6 citations · risk-based survey (a shorter visit CMS gives only to higher performing homes)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and resident record reviews, the facility failed to ensure call lights were in reach. This affected two residents (#8 and #67) of three residents reviewed for call lights. The facility census was 79.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, resident record review, resident interview, and staff interviews, the facility failed to accurately assess and document a resident's hearing status on the minimum data set (MDS) assessment. This affected one resident (#1) of four residents reviewed for assessments. The facility census was 79.
- 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 observations, resident record review, resident interview, and staff interviews, the facility failed to develop and implement a comprehensive care plan to reflect a resident's hearing impairment. This affected one resident (#1) of one resident reviewed for care planning. The facility census was 79.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, resident record reviews, interviews, review of a Self-Reported Incident (SRI) and facility policy review, the facility failed to provide adequate assistance with activities of daily living (ADL) for dependent residents. This affected two residents (#1 and #86) of four residents reviewed for ADL care. The facility census was 79.
- 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 provide care planned interventions to prevent resident falls. This affected one (Resident #67) of two residents reviewed for accident hazards. The total census was 79.
- 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, record review and interview, the facility failed to appropriately track and account for dispensed narcotics. This affected one (Resident #18) of three residents reviewed for narcotic tracking. The facility census was 79.
April 10, 2025Complaint inspection · 2 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, review of the medical record, review of facility policy, and interview with staff, the facility failed to provide privacy during wound care to Resident #1. This affected one resident (Resident #1) of one observed for wound care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, review of the medical record, interview with staff, and review of policy and procedure, the facility failed to maintain infection control during wound care for Resident #1's pressure ulcer. This affected one resident (Resident #1) of three reviewed for pressure ulcers.
December 12, 2024Standard inspection · 1 citation
- B
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 record review and staff interview, the facility failed to ensure the State Ombudsman was notified of resident discharges. This affected one resident (Resident #4) of two residents reviewed for discharge and had the potential to affect all 76 residents in the facility. Findings revealed: Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hereditary spastic paraplegia (inherited leg weakness), osteoporosis, joint derangements, major depressive disorder, mild cognitive impairment, dysphagia, abnormal involuntary movements, secondary scoliosis, malnutrition, cerebral infarction, chronic osteomyelitis, and multiple sclerosis. Review of progress notes revealed Resident #4's cognition was impaired. [...]
November 4, 2024Complaint inspection · 2 citations
- 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 the facility policy, the facility failed to timely notify resident representatives of significant changes in health status. This affected one (Resident #79) of three residents reviewed for falls. The facility census was 77 residents.
- 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, staff interview, resident representative interview, and review of the facility policy, the facility failed to implement interventions to prevent falls. This affected one (Resident #79) of three residents reviewed for falls. The facility census was 77 residents.
September 15, 2022Standard inspection · 7 citations
- E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on record review and interview the facility failed to ensure residents and/or their representatives were notified in writing when their personal fund account (PNA) reached $200.00 less than the Medicaid resource limit (of $2000.00). This affected four residents (#9, #49, #53 and #67) of six resident records reviewed for PNA accounts.
- E
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 the facility failed to provide written notifications to residents and residents' representatives before transfer to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization.
- E
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 interview the facility failed to provide timely written notifications to residents or residents' representatives related to the bed hold policy when residents were transferred to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview the facility failed to ensure Resident #36 received the appropriate beneficiary notice when skilled services were discontinued. This affected one resident (#36) of three residents reviewed for beneficiary notices.
- 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 interview the facility failed to refer a resident with newly evident or possible serious mental disorder for a pre-admission screening and resident review (PASARR) Level II review. This affected one resident (#65) of two residents reviewed for PASARR.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #59 was assisted with her breakfast meal in a timely manner. This affected one resident (#59) and had the potential to affect seven additional residents (#16, #26, #27, #29, #31, #47 and #53) who resided on the third floor and required staff assistance with meals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review and interview the facility failed to ensure fall interventions were implemented as plan to decrease the risk of falls/injury for Resident #20 and Resident #274. This affected two residents (#20 and #274) of three residents reviewed for accidents.
Fire safety inspections
28 fire safety citations on file: 3 on March 2, 2026, 9 on December 12, 2024, 16 on September 15, 2022.
Every fire safety citation28 citations
- 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 2, 2026 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · March 2, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 2, 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 · December 12, 2024 · Corrected (the home has a date of correction)
- F
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 · December 12, 2024 · Waiver
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 12, 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 · December 12, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · September 15, 2022 · Waiver
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · September 15, 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 · September 15, 2022 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · September 15, 2022 · Corrected (the home has a date of correction)
- E
Provide at least two remote exits on each floor or fire section of the building.
K 252 · September 15, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 15, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · September 15, 2022 · Corrected (the home has a date of correction)