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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
1F
Potential for minimal harm
0A
0B
0C
February 5, 2026Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, record reviews, and review of facility's bowel management process, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (Resident #1, #2, and Resident #4) of three residents reviewed for management of constipation, by failing to implement medical director's directive/order to administer stool softeners/laxatives.
January 8, 2026Standard inspection · 0 citations
January 19, 2024Standard inspection · 5 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide one dependent resident (#8) from a total sample of 35 residents, with services to carry out activities of daily living necessary to maintain appropriate grooming and personal hygiene. Resident #8 was not provided adequate fingernail care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one (Resident #96) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and resident choices, based on the resident's and resident representative's desire to have bilateral compression stockings placed on lower extremities daily as ordered.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, medical record review, interviews, and review of the policy and procedure for Following Physicians' Orders (revised 1/2024), the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #111) of two residents selected for pressure ulcer review, from a total sample of 35 residents. Resident #111 suffered deterioration of a sacral pressure wound which was facility-acquired.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff and resident interviews, medical record review, and a review of facility policy, the facility failed to ensure that two (Resident #56 and #94) of 35 residents in the total sample, were provided an environment as free of accident hazards as was possible.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent. Three errors were identified out of 26 opportunities for error, resulting in a medication error rate of 11%, involving two (Residents #50 and #99) of four residents observed during medication administration, from a total of 35 residents in the sample.
February 10, 2022Standard 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 kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Specifically, the facility failed to ensure that the dietary staff were trained and knowledgeable about proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents, due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. This failure potentially impacted every resident consuming food from the facility's kitchen.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate an allegation of sexual abuse by failing to promptly identify one (Resident #35) of nine hospice residents as a potential victim of an alleged perpetrator's actions.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively manage a resident's pain, by failing to identify and respond to non-verbal indicators of pain for one resident (Resident #7) reviewed for pain management from a total sample of 35 residents.
Fire safety inspections
12 fire safety citations on file: 9 on January 8, 2026, 3 on January 19, 2024.
Every fire safety citation12 citations
- D
Address subsistence needs for staff and patients.
E 15 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Meet the requirements of an integrated health system.
E 42 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · January 8, 2026 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 19, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 19, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 19, 2024 · Corrected (the home has a date of correction)