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 7 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
1E
0F
Potential for minimal harm
0A
0B
0C
March 19, 2026Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure an accurate MDS assessment for 1 of 25 residents, Resident #2.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, staff interview, clinical record review and facility document review the facility staff failed to follow medical provider orders for 2 of 25 residents, Resident #5 and Resident #8.
February 8, 2023Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty residents in the survey sample (Resident #56).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medication pass and pour observation, staff interview, and clinical record review the facility staff failed to follow physician's orders for Resident # 58.
May 5, 2021Standard inspection · 3 citations
- E
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 clinical record review and staff interview, the facility staff failed to ensure a pharmacy GDR [gradual dose reduction] recommendation was completed for one of 20 residents [Resident #8]. Resident #8's physician signed a GDR pharmacy recommendation for Lunesta [a hypnotic medication for sleep] to be decreased from 2 mg [milligrams] to 1 mg nightly; however, Resident #8 continued to received 2 mg nightly for over 5 months.
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on review of employee personnel files and staff interview, the facility failed to ensure one of 25 employees reviewed was currently licensed. A Certified Nursing Assistant (CNA A), was working with an expired license, and did not renew the licensed until [DATE].
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of 20 residents in the survey sample. Resident #18's clinical record documented an inaccurate response to a pharmacy recommendation regarding use of an antipsychotic medication and documented psychotropic medication management by a consultant when psychiatric services had been discontinued.
Fire safety inspections
11 fire safety citations on file: 1 on March 19, 2026, 2 on February 8, 2023, 8 on May 5, 2021.
Every fire safety citation11 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 19, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 8, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 5, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 5, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 5, 2021 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · May 5, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · May 5, 2021 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 5, 2021 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · May 5, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 5, 2021 · Corrected (the home has a date of correction)