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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
1E
0F
Potential for minimal harm
0A
0B
0C
June 3, 2025Standard inspection · 4 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's advanced directives were updated for 1 of 1 resident reviewed for advanced directives. (Resident 19) Finding Includes: The clinical record for Resident 19 was reviewed on [DATE] at 2:04 p.m. The diagnoses included, but were not limited to, right hip fracture, cognitive communication deficit, metabolic encephalopathy, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation. A current care plan, dated [DATE], indicated Resident 19 had advanced directives. The care plan was not specific on what his advanced directives included. Interventions included, but were not limited to, advanced directives reviewed quarterly and as needed, code status as ordered, and honor durable POA's (Power of Attorney) decision. [...]
- 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 a resident received a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR. (Resident 46)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily weights were obtained as ordered and to ensure the physician was notified of weight changes as ordered for 2 of 2 residents reviewed for quality of care. (Resident 9 and 10)
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were prescribed as ordered to prevent significant medication errors for 1 of 1 resident reviewed for medication errors. (Resident 202)
April 26, 2024Standard inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to ensurefood was handled to maintain food safety related to discarding and thawing. 52 of 52 residents residing in the facility ate food prepared in the kitchen.
January 18, 2024Complaint inspection · 1 citation
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure nonpharmacological interventions were implemented prior to administering a duplicate antianxiety medication, to document potential medication side effects and to ensure a duplicate antianxiety medication had a clinical rationale for the continued use of the medication for 1 of 3 residents reviewed for unnecessary medication. (Resident C)
January 26, 2023Standard inspection · 5 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for a resident who was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR. (Resident 42)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to assess for edema and notify the physician of a significant weight gain for 1 of 6 residents reviewed for quality of care. (Resident 155)
- 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 consultant pharmacist made recommendations for irregularities in diagnoses and medications prescribed for 1 of 2 residents reviewed for unnecessary psychotropic medications. (Resident 42)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for antibiotics was followed for 1 of 5 residents reviewed for unnecessary medications. (Resident 19)
- 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 a resident with dementia had an appropriate diagnosis for the use of an antipsychotic medication and a mood stabilizing medication and to ensure recommendations for parameters of laboratory levels were followed for 1 of 2 residents reviewed for unnecessary psychotropic medications. (Resident 42)
Fire safety inspections
10 fire safety citations on file: 1 on June 3, 2025, 8 on April 26, 2024, 1 on January 26, 2023.
Every fire safety citation10 citations
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 3, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 26, 2024 · 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 · April 26, 2024 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · April 26, 2024 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 26, 2024 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · April 26, 2024 · Corrected (the home has a date of correction)
- C
Develop a communication plan.
E 29 · April 26, 2024 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · April 26, 2024 · Corrected (the home has a date of correction)
- E
Have an enclosure around a vertical opening shaft.
K 311 · January 26, 2023 · Corrected (the home has a date of correction)