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 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
0E
4F
Potential for minimal harm
0A
0B
1C
January 27, 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 IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, facility investigation report review, and policy review, the facility failed to provide adequate physical assistance with bed mobility. This resulted in Actual Harm to Resident #43 when one staff person was changing the bed sheets and rolled Resident #43 out of bed onto the floor, resulting in a leg fracture. Resident #43 required the assistance of two staff for bed mobility. This affected one (Resident #43) of two residents reviewed for falls. The census was 32. Findings Include:Resident #43 was admitted to the facility on [DATE]. Pertinent diagnoses included Parkinson's disease, hereditary and idiopathic neuropathy, cerebrovascular disease, spondylosis, degenerative disease of nervous system, and fibromyalgia. [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and medical record review the facility failed to ensure Resident #2 and #28's care plans accurately reflected the resident's prescribed medications. This affected two residents (#2 and #28) of five residents reviewed for unnecessary medications. The facility census was 32.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, medical record review, and review of facility policies the facility failed to document on a new skin area for Resident #9 and provide documented justification for the start of an antibiotic. This affected one resident (#9) of two residents reviewed for skin conditions. The facility census was 32.
- 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 medical record review and staff interview, the facility failed to ensure pharmacy recommendations were completed in two separate quarters within the first year of admission. This affected one (Resident #32) of five residents reviewed for pharmacy recommendations. The census was 32. Findings Include: Resident #32 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, muscle wasting and atrophy, dysphagia, cognitive communication deficit, wedge compression fracture of first lumbar vertebra, hypertension, Alzheimer's disease, heart failure, atrial fibrillation, anxiety disorder, depression, mood disorder, and vascular dementia. Review of her minimum data set (MDS) assessment, dated 01/08/26, revealed she had a severe cognitive impairment. Review of Resident #32's physician orders revealed the following psychotropic medications: [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure blood pressure and pain medications were administered within the ordered parameters. This affected one resident (#17) of two reviewed for pain management. The facility census was 32.
- 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 record review, interview, review of hospice provider contract, and facility policy review, the facility failed to ensure hospice documentation was reviewed and consistent with facility orders and plan of care for a resident. This affected one resident (#6) reviewed for hospice. The facility census was 32.
March 21, 2024Standard inspection · 7 citations
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, staff interview, review of the dietary spreadsheets, and facility policy review, the facility failed to ensure residents received appropriate portion sizes during a lunch meal. This had the potential to affect all 32 residents who received food from the kitchen.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to properly store and date food items in the freezer area of the kitchen and failed to utilize appropriate hand hygiene during lunch meal service. This had the potential to affect all 32 residents who received food from the kitchen.
- 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 record review, staff interview, and facility policy review, the facility failed to timely follow up on a pharmacy recommendations and implement the physician's response to the pharmacy recommendations. This affected two residents (Residents #10 and #178) of five residents reviewed for unnecessary medications. The facility census was 32.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, review of the facility policy, and staff interview the facility failed to ensure residents were free from unnecessary medications. This affected three (Resident #2, #9, and #10) of five residents reviewed for unnecessary medication use. The facility census was 32.
- 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 record review and staff interview, the facility failed to ensure the residents received ongoing monitoring of medication side effects for psychotropic and antianxiety medication. This affected two (Residents #8 and #19) of five residents reviewed for unnecessary medications. The facility census was 32.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of the facility policy, staff interview, observation, and record review, the facility failed to ensure staff sanitized their hands after glove changes during a suprapubic indwelling catheter dressing change. This affected one (Resident #21) of three residents reviewed for urinary catheter or urinary tract infection. The facility identified three residents with urinary catheters. The facility census was 32.
- D
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to implement their antibiotic stewardship program to ensure infections and antibiotics were monitored. This affected two (Residents #2 and #10) of three residents reviewed for antibiotic use. The facility census was 32.
September 13, 2021Standard inspection · 4 citations
- 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 and staff interview, the facility failed to ensure a sanitary environment for food preparation. This had the potential to affect all 23 residents residing in the facility. Facility census was 23.
- F
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 and staff interview, the facility failed to ensure a safe environment when staff propped open a fire door. This had the potential to affect all 23 residents residing in the facility. Facility census was 23.
- 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 medical record review and staff interviews, the facility failed to ensure residents were free from unnecessary psychotropic drugs when the facility failed to ensure as needed orders for anti-anxiety medications (Lorazepam) was limited to 14 days. This affected three (#21, #5 and #15) out of five residents reviewed for unnecessary medications. Facility census was 23.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, review of the posted staffing information and staff interview, the facility failed to post complete and accurate numbers of nurse staffing information as required. This had the potential to affect all 23 residents residing in the facility. The census was 23.
Fire safety inspections
8 fire safety citations on file: 4 on January 27, 2026, 1 on March 21, 2024, 3 on September 13, 2021.
Every fire safety citation8 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · January 27, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 27, 2026 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 27, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 27, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 13, 2021 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 13, 2021 · Corrected (the home has a date of correction)
- D
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
K 913 · September 13, 2021 · Corrected (the home has a date of correction)