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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
0E
0F
Potential for minimal harm
0A
0B
2C
April 29, 2026Standard inspection · 3 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff propelled Resident (R) 49, R29, R28, and R24 through the hallway in wheelchairs without having foot pedals, requiring the residents to hold their feet up while being pushed.
- 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, the facility failed to adequately store medications and/or biologicals when staff failed to lock an unattended medication cart.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to display accurate posted nurse staffing information which contained all the required data.
July 17, 2024Standard inspection, Complaint inspection · 2 citations
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wrote- R36's Electronic Medical Record (EMR) documented R36 had a diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). R36's Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented the resident required partial to moderate staff assistance with most activities of daily living (ADLs) and received oxygen therapy. [...]
- 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 wroteThe facility had a census of 77 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure nonpharmacological symptom management and a specified duration of use for Resident (R) 19 and R18's use of as-needed (PRN) psychotropic (alters mood or thoughts) medication. The facility further failed to ensure an appropriate indication of use or a documented physician rationale and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) and for not attempting a gradual dose reduction (GDR) for R33 and failed to ensure R18's PRN antipsychotic medication had the required 14-day stop date. This placed the residents at risk of receiving unnecessary psychotropic medications.
March 28, 2023Standard inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect during dining for Resident (R) 3, R12 and R20. This placed the residents at risk for an undignified dining experience.
- 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 wroteThe facility had a census of 59 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)18, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.
- C
Post nurse staffing information every day.
Inspectors wroteThe facility had a census of 59 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to post the actual working hours for nursing staff directly responsible for resident care per shift as required.
Fire safety inspections
37 fire safety citations on file: 7 on April 29, 2026, 18 on July 17, 2024, 12 on March 28, 2023.
Every fire safety citation37 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 29, 2026 · deficient, provider has
- F
Have simulated fire drills held at unexpected times.
K 712 · April 29, 2026 · deficient, provider has
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · April 29, 2026 · deficient, provider has
- 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 29, 2026 · deficient, provider has
- E
Install corridor and hallway doors that block smoke.
K 363 · April 29, 2026 · deficient, provider has
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 29, 2026 · deficient, provider has
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 29, 2026 · deficient, provider has
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · July 17, 2024 · Corrected (the home has a date of correction)
- F
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 17, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 17, 2024 · 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 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 17, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · July 17, 2024 · 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 17, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 17, 2024 · Waiver
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 17, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 28, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 28, 2023 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 28, 2023 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 28, 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 28, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 28, 2023 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 28, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 28, 2023 · Corrected (the home has a date of correction)