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
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
11D
0E
1F
Potential for minimal harm
0A
0B
0C
July 24, 2026Standard inspection, Complaint 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 interview and record review it was determined the facility failed to ensure the care plan related to dining was followed for 1 of 7 sampled residents (#151) reviewed for accidents. This placed residents at risk for choking.
April 23, 2026Complaint inspection · 1 citation
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled resident (#6) reviewed for medication administration. This placed residents at risk for adverse medication consequences.
April 11, 2025Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wrote1. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 1 of 6 halls reviewed for dining. This placed residents at risk for cross contamination.
- 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 it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#36) reviewed for ADLs. This placed residents at risk for lack of personal hygiene.
January 3, 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, it was determined the facility failed to follow care plan interventions related to aspiration risks for 1 of 3 sampled residents (#3) reviewed for accidents. Resident 3 admitted to the facility in 2024 with diagnoses including traumatic subdural hemorrhage (severe head injury) and dysphagia (difficulty with swallowing). Resident 3's 9/3/24 Care Plan indicated the resident required one on one eating assistance due to dysphagia. The care plan stated staff were not to deliver until staff was ready to assist the resident. The 9/2024 admission MDS identified Resident 3 was cognitively intact. A 9/4/24 choking/aspiration investigation revealed Staff 5 (CNA) delivered Resident 3's lunch tray to the resident and informed Resident 3 that she would return to assist Resident 3 after delivering the last lunch tray. [...]
March 20, 2024Complaint 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 interview and record review it was determined the facility failed to ensure the plan of care was followed to provide care-planned assistance to prevent a fall for 1 of 3 sampled residents (#3) reviewed for falls. This resulted in Resident 3's hospitalization with leg fracture and surgical repair.
December 18, 2023Standard inspection, Complaint inspection · 9 citations
- J
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 it was determined the facility failed to assess elopement risk and provide supervision to prevent a severely cognitively impaired resident from eloping for 1 of 3 sampled residents (#272) reviewed for elopement. This failure resulted in an immediate jeopardy situation when Resident 272 eloped from the facility, was exposed to cold and rainy weather conditions, was without supervision at night in a high-traffic area, and was at risk for wandering into additional unsafe areas and getting lost. This placed the resident at risk for hypothermia, accidents, and a lack of access to support services.
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to prevent the development of moisture associated skin damage (MASD) and follow physician orders for 2 of 3 sampled residents (#s 322 and 372) reviewed for skin conditions and pain management. This failure resulted in Resident 372 developing MASD and placed residents at risk for increased pain.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 1 sampled resident (#324) reviewed for activities. This placed residents at risk for being treated in a dishonorable manner.
- 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 interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition for 1 of 1 sampled resident (#372) reviewed for change of condition. This placed residents at risk for having uninformed responsible parties.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled residents (#s 373 and 374) reviewed for Notice of Medicare of Non-Coverage (NOMNC). This placed residents at risk for unknown financial liabilities.
- 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 interview and record review it was determined the facility failed to provide adequate bowel and bladder care for 2 of 3 sampled residents (#s 48 and 118) reviewed for bowel and bladder. This placed residents at risk for skin breakdown.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy and to ensure respiratory equipment was maintained for 1 of 1 sampled resident (#89) reviewed for respiratory care. This placed residents at risk for adverse respiratory complications and outcomes.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 2 of 7 sampled residents (#s 17 and 57) reviewed for medication administration. The facility's medication error rate was 10.71%. This placed residents at risk for adverse medication consequences.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure 2 of 9 medication carts were properly secured during random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
Fire safety inspections
11 fire safety citations on file: 6 on July 24, 2026, 2 on April 11, 2025, 3 on December 18, 2023.
Every fire safety citation11 citations
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · July 24, 2026 · deficient, provider has
- F
Provide properly protected cooking facilities.
K 324 · July 24, 2026 · deficient, provider has
- F
Have simulated fire drills held at unexpected times.
K 712 · July 24, 2026 · deficient, provider has
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 24, 2026 · deficient, provider has
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 24, 2026 · deficient, provider has
- D
Have proper medical gas storage and administration areas.
K 923 · July 24, 2026 · deficient, provider has
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 11, 2025 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · April 11, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 18, 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 18, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 18, 2023 · Corrected (the home has a date of correction)