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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
16D
0E
3F
Potential for minimal harm
0A
0B
0C
March 31, 2026Complaint inspection · 1 citation
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident's pain medication was administered for pain control. This applies to 1 of 5 residents (R1) reviewed for pain in the sample of 5.
January 21, 2026Complaint inspection · 3 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from misappropriation of monies. This applies to 1 of 3 residents (R2) reviewed for misappropriation in the sample of 8.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation of a resident's monies. This applies to 1 of 3 residents (R2) reviewed for misappropriation in the sample of 8.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with the diagnosis of dementia and known aggressive behaviors was cared for in a manner to prevent injury. This applies to 1 of 3 residents (R1) reviewed for dementia in the sample of 8.
January 5, 2026Complaint inspection · 1 citation
- G
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 ensure fall prevention interventions were in place for a resident with a history of falls for 1 of 3 residents (R1) reviewed for falls in the sample of 6. This failure resulted in R1 falling and sustaining a right hip fracture and right knee fracture.
December 10, 2025Standard inspection · 5 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review the facility failed to ensure bed hold notices were provided for 2 residents (R1, R38) and failed to notify the ombudsman of resident transfers and discharges for 3 of 3 residents (R1, R38, R40) reviewed for discharge requirements in the sample of 12.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided timely for a resident that requires assistance for one of 12 residents (R32) reviewed for ADL care in the sample of 12.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure injury for one of two residents (R3) reviewed for pressure injuries in the sample of 12.
- 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 supervise a resident with a high risk of falls and a history of falls for 1 of 12 residents (R2) reviewed for safety and supervision in the sample of 12.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 28 opportunities with three errors resulting in a 10.71% error rate. This applies to two of five residents (R30, R24) observed in the medication pass.
December 7, 2025Complaint inspection · 2 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 identify a pressure wound before developing into an unstageable pressure injury for one (R1). The facility also failed to prevent the development of three facility acquired State 2 pressure ulcers and one facility acquired unstageable pressure ulcer, a Stage 2 pressure ulcer worsening to unstageable, prevent cross contamination during dressing changes and apply pressure reduction devices for one (R2). This failure applies to two of three residents (R1 & R2) reviewed for pressure on the total sample of three.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore personal protective equipment when providing a dressing change for 1 of 3 residents (R3) reviewed for wounds in the sample of three.
February 18, 2025Complaint inspection · 1 citation
- 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 ensure staff safely transferred a resident who has history of falls. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3.
January 10, 2025Complaint inspection · 1 citation
- G
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 ensure resident coffee was served at a safe temperature for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of four. This failure resulted in R1 sustaining second degree burns to her thigh and calf.
October 11, 2024Standard inspection · 4 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, interview and record review, the facility failed to ensure staff covered an open wound, and failed to ensure food was prepared and served in a sanitary manner. These failures have the potential to affect all of the residents in the facility.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's physician was notified when blood glucose levels were out of the set parameters ordered by the physician for 1 of 1 resident (R5) reviewed for blood glucose levels in the sample of 14.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess pressure wounds weekly for 2 of 4 residents (R23, R15) reviewed for pressure ulcers in the sample of 14.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to perform incontinence care in a manner to prevent cross contamination (R15), failed to initiate enhanced barrier precautions for a resident with an indwelling catheter and open wounds (R25), and failed to administer medications in a manner to prevent cross contamination (R18) for 3 of 3 residents (R15, R25, and R18) reviewed for infection control in the sample of 14.
April 1, 2024Complaint inspection · 1 citation
- 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 ensure fall interventions were in place for residents with a history of falls for 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 3.
December 20, 2023Standard inspection · 3 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, interview and record review the facility failed to ensure food was stored, prepared and distributed in a manner to prevent cross-contamination, failed to ensure food items in the refrigerator and freezer were labeled and dated with an open date and failed to ensure that kitchen was kept in sanitary condition. This applies to all 36 residents residing in the the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff used required personal protective equipment (PPE) when entering an isolation room, failed to perform hand hygiene to prevent cross contamination and failed to ensure residents and staff were tested for COVID-19 to prevent the spread of infection. This applies to all 36 residents residing in the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer preventions were in place and failed to ensure ordered treatments were in place for one of four residents (R89) reviewed for pressure injuries in the sample of 15.
Fire safety inspections
7 fire safety citations on file: 1 on October 11, 2024, 4 on December 20, 2023, 2 on March 16, 2023.
Every fire safety citation7 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 11, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 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 · December 20, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 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 · December 20, 2023 · 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 · March 16, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 16, 2023 · Corrected (the home has a date of correction)