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
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
2E
0F
Potential for minimal harm
0A
0B
1C
January 21, 2026Standard inspection · 4 citations
- J
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified immediately and on-call services were utilized when a resident had a change of condition for 1 of 3 discharged residents reviewed for notification of change. (Resident 67) Resident 67 was admitted to the hospital with a bowel obstruction, perforated bowel, and necrosis. The resident required surgical intervention and subsequently died. The immediate jeopardy began, on [DATE] around 9:40 p.m., when Resident 67 had a change of condition which included, a complaint of constipation with ongoing diarrhea, increased pain, shortness of breath, loss of bowel sounds, and excessive belching. RN 2 faxed the physician's office at this time. On [DATE] at 1:58 a.m., Resident 67 was yelling out about abdominal pain and excessive belching. RN 3's assessment noted hypoactive bowel sounds. [...]
- 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 to ensure the resident and/or resident's representative was provided in writing the facility's bed hold policy upon transfer for 3 of 3 residents reviewed for hospitalization. (Resident 64, 67 and 3)
- 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 PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Residents 5)
- 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 daily weights were obtained as ordered by the physician for 1 of 1 resident reviewed for quality of care. (Resident 9)
February 25, 2025Standard inspection · 6 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure behavior and side effect monitoring for psychotropic medications, wound care treatments, and catheter care were documented for 4 of 4 residents reviewed for documentation. (Resident 18, 33, 20 and 12)
- 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 staff followed the physician's ordered medication parameters were followed for 2 of 5 residents reviewed for quality of care. (Residents 45 and 33)
- 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 physician's orders were followed and therapy evaluations were completed in a timely manner for 2 of 4 residents review for position and mobility. (Resident 51 and 9)
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff initiated new person-centered dementia care interventions for residents with wandering behaviors and to check wanderguard placement for 2 of 5 residents reviewed for dementia care. (Resident B and C)
- 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 the pharmacy provided gradual dose reduction (GDR) requests to reduce or discontinue psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 18, and 33)
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure influenza and pneumococcal vaccinations were provided for 1 of 5 residents reviewed for immunizations. (Resident B)
January 26, 2024Standard inspection · 5 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote4. During an observation, on 1/23/24 at 12:31 p.m., Resident 25 was observed, in her wheelchair, wearing open toe sandals with a small bandage on her left great toe. During an observation, on 1/26/24 at 11:17 a.m., the resident was sitting up, in her wheelchair, she had sandals on, and a small bandage was noted on her left great toe. The bandage was not dated and had some red drainage present. The clinical record for Resident 25 was reviewed on 1/26/24 at 10:50 a.m. The diagnosis included, but were not limited to, Alzheimer disease, type 1 diabetes mellitus with diabetic neuropathy, bell's palsy, osteoarthritis, and venous insufficiency. A physician's order, dated 1/18/24, indicated the resident may be seen by a wound doctor. A podiatrist note, dated 1/18/24, indicated the resident had non palpable pulses in her bilateral feet and edema was noted. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received mouth care twice daily for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident 37)
- 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 all areas of the wireless call system were functioning properly for 2 of 2 residents reviewed for call devices. (Residents 19 and 13)
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure items were not stored on the floor in resident rooms, carpet squares edges were not peeling, and the walls were free of gouges for 4 of 4 rooms reviewed for environment. (Room A10, A9, A3 and C11D.)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure posted nurse staffing was up to date and had the correct hours of staff nurses for 2 of 2 posted nurse staffing lists. (1/23/24 and 1/24/24)
Fire safety inspections
6 fire safety citations on file: 2 on January 21, 2026, 2 on February 25, 2025, 2 on January 26, 2024.
Every fire safety citation6 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 21, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 21, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 26, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 26, 2024 · Corrected (the home has a date of correction)