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 4 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
0F
Potential for minimal harm
0A
0B
0C
April 9, 2026Standard inspection · 1 citation
- 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, interview, and record review, the facility failed to ensure that the residents' controlled medications were properly received and documented on according to facility policy by failing to: 1. Maintain documentation of receiving controlled medications, upon receipt of medication into the facility and maintaining administration information for controlled medications; this deficient practice affected two (R1 and R8) of two residents. This deficient practice affected two (R1 and R8) of two residents reviewed for controlled medication management in the sample of 60 and has the potential to affect all residents prescribed controlled medications in the facility.
February 20, 2025Standard inspection · 1 citation
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review, the facility failed to follow their policy related to psychotropic medications and ensure one resident (R49) was free from unnecessary psychotropic medications. Findings Include: R49 is an [AGE] year-old female who admitted to the facility on [DATE] and continues to reside in the facility. R49 has multiple diagnoses including but not limited to the following: difficulty in walking, lack of coordination, and osteoarthritis. Per physician orders resident is receiving Quetiapine Fumarate Oral Tablet 25 mg - Give 0.5 tablet by mouth at bedtime for sleep/anxiety. On 2/19/2025 at 12:25PM, R49 was noted to be calm and alert and oriented with no behaviors. On 2/19/2025 at 1:30PM, V2 (Director of Nursing) said, R49 came to the facility already receiving an antipsychotic medication. [...]
April 25, 2024Standard inspection · 0 citations
December 11, 2023Complaint inspection · 2 citations
- 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 safely transfer a resident (R1) with a mechanical lift. This applies to 1 of 3 residents reviewed for safety & supervision in the sample of 4.
- 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 observation, interview, and record review, the facility failed to perform incontinence care and provide catheter care in a manner to prevent urinary tract infections for 1 resident. The facility also failed to position a resident's urinary catheter bag off the floor for 1 resident. These failures apply to 2 of 3 residents (R1, R2) reviewed for incontinence care in the sample of 4.
Fire safety inspections
18 fire safety citations on file: 8 on February 20, 2025, 4 on April 25, 2024, 6 on April 14, 2023.
Every fire safety citation18 citations
- F
Conduct testing and exercise requirements.
E 39 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 20, 2025 · Corrected (the home has a date of correction)
- 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 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · February 20, 2025 · 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 · February 20, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 20, 2025 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · April 25, 2024 · 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 · April 25, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 25, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 14, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 14, 2023 · Corrected (the home has a date of correction)
- 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 · April 14, 2023 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · April 14, 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 · April 14, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 14, 2023 · Corrected (the home has a date of correction)