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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
1E
0F
Potential for minimal harm
0A
0B
1C
March 31, 2026Complaint 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, the facility failed to ensure a resident was kept safe during a transfer by a staff member for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a minimally displaced oblique fracture of the mid tibial diaphysis (a stable, angled break in the middle shaft of the shinbone) and a minimally displaced spiral fracture of the proximal fibular diaphysis (a stable, low-energy injury near the knee). The deficient practice was corrected on 3/27/26, prior to the start of the survey, and therefore was past noncompliance.
November 25, 2025Standard inspection · 3 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Record Review (PASARR) screenings were accurate when completed and updated when new mental health diagnoses and medications were initiated for 2 of 2 residents reviewed for PASARR. (Resident 3 and 19)
- 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, the facility failed to ensure a resident received assistance with personal hygiene for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident 29)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a daily weight was obtained as ordered by the physician for 1 of 1 resident reviewed for edema. (Resident 6)
November 25, 2024Standard inspection · 7 citations
- 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, the facility failed to ensure a resident who needed assistance with eating was assisted timely for 1 of 11 residents observed in the dining room. (Resident 10)
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) Level I was submitted after a new mental health diagnoses was added and an antidepressant medication was prescribed for 1 of 1 resident reviewed for PASARR. (Resident 1)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was held per the physician's order for 1 of 1 resident reviewed for quality of care. (Resident 131)
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff obtained a follow-up weight and notified the physician of a weight gain for 1 of 1 resident reviewed for weight changes. (Resident 1)
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments were completed and consent was obtained prior to the use of side rails for 1 of 2 residents reviewed for accident hazards. (Resident 21)
- 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 ensure the policy and procedure for conducting an Abnormal Involuntary Movement Scale (AIMS) assessment upon admission and quarterly was followed for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 16)
- 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 ensure medication carts were free from expired medications, medical supplies, and loose pills, and medications were properly labeled after opening for 1 of 2 medication carts reviewed for medication storage and labeling. (Hall 1)
December 1, 2023Standard inspection, Complaint inspection · 9 citations
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of significant weight changes for 4 of 6 residents reviewed for nutrition. (Residents 24, 10, 14, and 18)
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were in reach and a bed was not in a high position for 1 of 1 resident reviewed for accommodation of needs. (Resident 23)
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to submit a revised Preadmission Screen and Resident Review (PASARR) Level I after a new mental health diagnoses and the resident was prescribed an antipsychotic and antianxiety medication for 1 of 1 resident reviewed for PASARR. (Resident B)
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to update care plans for an anticoagulant and a diuretic medication for 1 of 1 resident reviewed for care plans. (Resident 4)
- 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, the facility failed to provide incontinence care for 1 of 3 residents reviewed for Activity of Daily Living (ADL). (Resident B)
- 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 keep a catheter bag from touching the ground for 1 of 2 residents reviewed for urinary catheter. (Resident 230)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wrote2. The record for Resident 230 was reviewed on 11/29/23 at 12:05 p.m. Diagnoses included, but were not limited to, encephalopathy (disease which caused confusion), history of stroke, heart failure, and cognitive communication deficit. A physician's order, dated 11/17/23, indicated the resident was taking Eliquis 5 mg tablet twice per day. There was no physician's order or care plan to monitor for bleeding in the resident's record. During an interview, on 11/30/23 at 2:49 p.m., the DON (Director of Nursing) indicated if a resident was on an anticoagulant medication, then there should be monitoring for the risk of bleeding. A current policy, titled Anticoagulation - Clinical Protocol. [...]
- 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 ensure supplements were secured in a resident's room for 1 of 1 resident reviewed for medication storage. (Resident 3)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to have nurse staffing posted and, in a location, where it could easily be viewed for 4 of the 5 days during the survey. (November 27, 28, 29 and 30)
Fire safety inspections
5 fire safety citations on file: 1 on November 25, 2025, 2 on November 25, 2024, 2 on December 1, 2023.
Every fire safety citation5 citations
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 25, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 25, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · November 25, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 1, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 1, 2023 · Corrected (the home has a date of correction)