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
1G
0H
0I
Potential for more than minimal harm
9D
1E
4F
Potential for minimal harm
0A
0B
0C
April 1, 2026Standard inspection, Complaint inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation pertains to intake: 2614163Based on interview and record review, the facility failed to implement fall preventions for one Resident (R6) of two residents reviewed for falls. This deficient practice resulted in a fractured 5th digit for R6 when a fall mat and bed alarm were not in place and functioning.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to:Implement an infection prevention and control program (IPCP) that included infection identification and surveillance to prevent the transmission of infectious organisms to all 24 residents in the facilityTrack and correlate a contagious and infectious organism for one Resident (R25) of five residents reviewed for infection prevention and control.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed toEnsure a discharge summary included a reconciliation of pre-discharge medications with the resident's post-discharge medications, and;Issue written notification of transfer for two Residents (R32 and R30) of four residents reviewed for closed records.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRR) were addressed by the attending physician for three Residents (R16, R3, & R4) of five residents reviewed for MRR and unnecessary medications.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review, the facility failed to provide hospice documentation for two Residents (R2, and R22) out of two residents reviewed for hospice care services. This deficient practice resulted in incomplete documentation for services that were provided by hospice.
February 13, 2025Standard inspection · 4 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 27 residents in the facility.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review the facility failed to provide evidence of documented monthly pharmacy medication regimen reviews (MRRs) and failed to appropriately follow a pharmacy recommendation for four Residents (3, 10, 15, 21) out of five residents reviewed for medication review. This deficient practice resulted in the potential for adverse medication side effects.
- 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: 1. Indicate a specific end date for as needed (PRN) psychotropic (drug that affects brain activity) medication for Residents #21. 2. Conduct an Abnormal Involuntary Movement Scale (AIMS) assessment (measures side effects of medications, i.e. tardive dyskinesia) for two Residents (#3 and #10), from a total of five residents reviewed for unnecessary medications.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functional call light for one Resident (#129) of 12 residents reviewed for operational call lights. This deficient practice resulted in dissatisfaction with the timeliness of the provision of care and fear that care needs may not be met in an emergency.
March 27, 2024Standard inspection, Complaint inspection · 5 citations
- F
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely Electronic Medical Record (EMR) access for their annual recertification survey.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis citation pertains to intake: MI00143410 Based on interview and record review, the facility failed to prevent staff to resident verbal and physical abuse for three Residents (R3, R14, R19) of three residents reviewed for abuse. This deficient practice resulted in R19 expressing fear of exposure to continued rough treatment during cares and fear of retaliation and the likelihood of feeling degraded by derogatory and profane comments by R3 and R14 based on the reasonable person concept.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThis citation pertains to intake: MI00143410 Based on interview and record review, the facility failed to report staff to resident verbal abuse for two Residents (R3, R14) of three residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to conduct thorough investigations for allegations of verbal abuse for two Residents (R3, R14) of three residents reviewed for abuse. This deficient practice resulted in the potential for additional unidentified abuse.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one Resident (R22) with limited mobility was appropriately set up for meal service to maintain mobility out of three residents reviewed for Range of Motion (ROM). This deficient practice resulted in R22 appearing to experience not being able to feed himself easily and the potential for decreased mobility and ROM.
Fire safety inspections
10 fire safety citations on file: 5 on April 1, 2026, 5 on March 27, 2024.
Every fire safety citation10 citations
- F
Develop Emergency Preparedness policies and procedures.
E 13 · April 1, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 1, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 1, 2026 · Corrected (the home has a date of correction)
- 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 · April 1, 2026 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · April 1, 2026 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · March 27, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures including evacuation.
E 20 · March 27, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · March 27, 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 · March 27, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 27, 2024 · Corrected (the home has a date of correction)