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
2G
0H
0I
Potential for more than minimal harm
8D
3E
1F
Potential for minimal harm
0A
0B
1C
July 9, 2026Standard inspection · 6 citations
- E
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure triggers were addressed for residents with post-traumatic stress disorder (PTSD). This affected four (#3, #11, #76 and #81) of four residents reviewed for trauma informed care. The facility identified four residents (#3, #11, #76 and #81) as having a diagnosis of PTSD. The facility census was 104.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, and interview the facility failed to ensure staff treated residents with respect and dignity. This affected one resident (Resident #57) out of four residents reviewed for dignity. The facility census was 104.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteOxygen tubing: Based on observation, interview, record review and review of facility policy, the facility failed to ensure a nebulizer mask was stored in a manner to prohibit contamination. This affected one (Resident #17) of one resident reviewed for respiratory care. The facility census was 104.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure proper hand hygiene was performed during wound care. This affected one (Resident #8) of two residents reviewed for wound care. The facility census was 104.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure education was provided to residents on the influenza vaccine. This affected two (Resident #8 and #22) of five residents reviewed for immunizations. The facility census was 104.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, review of the posted nurse staffing data report and staff interview, the facility did not ensure all required information was including on the posted nurse staffing report. This had the potential to affect all residents in the facility. The facility census was 104.
February 25, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, medical record review, review of a facility investigation, hospital records, facility policy, manufacturer's instructions, and interview, the facility failed to identify and implement comprehensive, individualized and adequate fall interventions to prevent a fall with injury during resident care. This affected one resident (#77) of three residents reviewed for accidents/incidents who required use of a shower gurney. The facility identified 32 residents (#3, #5, #11, #12, #21, #25, #27, #28, #29, #30, #33, #37, #41, #42, #43, #58, #59, #61, #62, #67, #77, #79, #81, #87, #89, #93, #94, #101, #103, #104, #112 and #114) who required a shower gurney for bathing. The facility census was 115. Actual Harm occurred on 01/11/26 at 3:00 P.M. [...]
November 4, 2024Complaint inspection · 1 citation
- D
Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #115's guardian was informed and gave consent for Resident #115 to be discharged from the facility. This affected one resident ( Resident # 115) of the three residents reviewed for discharge. The facility census was 114.
August 31, 2023Standard inspection · 1 citation
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview the facility failed to ensure all meals were served at an appetizing temperature. This had the potential to affect 108 residents at the facility. The facility identified one resident (#30) as receiving no food from the kitchen. The facility census was 109.
December 5, 2019Standard inspection · 6 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #94. Actual Harm occurred on 10/29/19 when Resident #94, who was quadriplegic and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed an unstageable/Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) pressure ulcer to the coccyx. This affected one resident (#94) of two residents reviewed for pressure ulcers. The facility identified eight current residents with pressure ulcers.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review and interview the facility failed to accurately code alarms on the Minimum Data Set (MDS) 3.0 assessment for Resident #29, Resident #63, Resident #96 and Resident #99. This affected four residents (#29, #63, #96 and #99) of four residents reviewed for alarms.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview the facility failed to maintain adequate infection control practices during the administration of medication for Resident #62 and during meal services to prevent the spread of infection. This affected one resident (#62) of six residents observed during medication administration and six residents (#10, #27, #63, #73, #85 and #87) of ten residents observed for meal service.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview the facility failed to ensure Resident #49 was free from misappropriation of money. This affected one resident (#49) of three residents reviewed for misappropriation.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #62, who had a diagnosis of diabetes mellitus received insulin injections in accordance with the physician's order for administration and to meet the resident's needs. This affected one resident (#62) of six residents observed for medication administration.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were administered to Resident #59 via gastrostomy tube to decrease the risk of stomach upset/gastrointestinal disturbance. This affected one resident (#59) six residents observed for medication administration.
Fire safety inspections
15 fire safety citations on file: 4 on July 9, 2026, 6 on August 31, 2023, 5 on December 5, 2019.
Every fire safety citation15 citations
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 9, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 9, 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 · July 9, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 9, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 31, 2023 · 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 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · August 31, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · August 31, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
K 132 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · December 5, 2019 · 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 · December 5, 2019 · Corrected (the home has a date of correction)
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · December 5, 2019 · Corrected (the home has a date of correction)