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 76 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
51D
23E
1F
Potential for minimal harm
0A
0B
1C
July 17, 2026Standard inspection, Complaint inspection · 19 citations
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on staff interviews and review of facility documentation it was determined the facility failed to ensure that a Performance Improvement Project (PIP) was identified and implemented through the facility's Quality Assessment and Assurance (QAA) committee and/or Quality Assurance Performance and Improvement (QAPI) program annually. This was found evident for 1 year of QAA/QAPI notes reviewed.
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on record review and interview, it was determined that the facility failed to maintain and account for scheduled Quality Assessment and Assurance meetings. This was evident for 5 of the 11 months QAA meetings were held July 2025- June 2026.
- E
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 resident's interview, it was determined that the facility failed to provide a safe, functional, sanitary, comfortable and homelike environment for residents. This was evident on 3 of 4 units and 1 of 1 observation of the courtyard during the survey.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure residents received reasonable accommodation of the call bell system. This was evident for 2 (Resident #5 and #32) of 24 residents observed during the initial screen process of the annual survey.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete an admission comprehensive Minimum Data Set (MDS) assessment within the required timeframe. This was evident for 1 (Resident #73) of 7 residents reviewed during the survey.
- 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 observation, interviews and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the needs of a Resident. This was found evident of 1 (Resident #13) out of 45 residents reviewed during the survey.
- 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 interviews and review of medical records it was determined that the facility failed to:1) update a care plan, 2) involve the Resident in the interdisciplinary care planning process. This was evident of 2 (Resident #7 and Resident #11) out of 45 residents reviewed during the survey.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure finger nail care was provided to residents. This was evident for 2 (Resident #24, and #71) of 2 residents observed for nail care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to provide treatments and appropriate follow-up for a resident's condition. This was found to be evident of 2 (Resident #92 & #11) out of 45 residents reviewed during the survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of medical records and interviews it was determined that the facility failed to adequately assist a dependent resident during Activity of Daily Living (ADL) cares. This was found evident for 1 (Resident #11) out of 6 residents reviewed for accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure respiratory care was provided in accordance with physician orders. This was evident for 3 (Resident #72, #20 & #73) of 4 residents observed during the recertification survey.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on record review and interviews with staff, it was determined that the primary medical provider failed to review and revise the total program of care. This was found evident for 1 (Resident #28) out of 45 residents reviewed during the survey.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on a complaint #3055819, record review and staff interviews, it was determined that the facility failed to provide evidence that accounts for some narcotic drug record use and reconciliation. This was evident for 1 of 3 nursing units reviewed for alleged narcotic misappropriation during the annual survey.
- 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 observation, record reviews and staff interviews, it was determined that the facility failed to carry out Pharmacist recommendations on three different occasions following the monthly medication regimen review (MRR). This was evident for 1(#6) of 5 residents reviewed for unnecessary medications.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that physicians' orders are followed. This was evidenced by staff giving as needed narcotics outside of the recommended parameters for 2 (Resident $42 and #75) of 5 residents reviewed for unnecessary medications during the annual survey. The findings Include. 1). On 07/15/2026 at 4:37 PM Review of the June 2026 Medication administration records (MAR) revealed that Resident #75 was getting their PRN (as needed) narcotic pain medication when their pain level was documented as zero on 6/3, 6/7, and 6/11. The order was to give oxycodone HCL oral tablet 5MG- Give 4 tablets by mouth every 4 hours as needed for severe pain level of 6-10. Further review of July 2026 MAR revealed a second PRN order for narcotic pain medication written as: Oxycodone HCL oral tab 5MG: [...]
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record reviews and staff interviews, it was determined that the facility failed to 1), store and serve food in a manner that prevents foodborne illness and 2), failed to date and label resident's food stored in the nourishment refrigerator. This was evident during the annual survey.
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on a complaint #3055819, record review and staff interviews, it was determined that the facility failed to employ a Registered Nurse (RN) in accordance with Maryland State laws. This was evident for 1 (Staff #2) of 3 employee files reviewed during the annual survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to separate the clean and soiled laundry areas with a closed barrier to prevent the potential for cross-contamination and failed to maintain a process to identify residents who required Enhanced Barrier Precaution (EBP). This was evident in the laundry room and 3 (#40, #44, and #54) out of 10 rooms observed for precaution signage.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that there was an effective pest control program in place at the facility to be free from pests. This was evident for several observations throughout the annual survey.
June 10, 2026Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on reviews of clinical records, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to 1) follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents, and 2) failed to document an associated blood pressure before administering the cardiac medication. This was evident for 1 (Residents #6) of 9 residents reviewed during a complaint survey.
May 15, 2026Complaint inspection · 3 citations
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review and staff interviews, the facility failed to provide the resident or representative with an outcome and/or resolution following the conclusion of a grievance investigation for 1 (R#12) of 6 sampled residents reviewed for grievances.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, record review, review of the facility-reported incident, review of the facility's Abuse Prevention Policy, and review of the facility's investigative documentation, the facility failed to ensure Resident #5 was free from verbal and mental abuse when a staff member yelled at the resident and threatened to have a family member come to the facility to 'take care' of the resident, for 1 of 3 sampled residents reviewed for abuse. Review conducted on 5/14/2026 at 10.15 AM. The Abuse Prevention Policy revealed that the facility policy prohibited verbal and mental abuse toward residents. The policy further indicated residents were to be free from verbal threats, intimidation, harassment, and abusive language by facility staff. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to ensure staff implemented interventions to prevent a resident from falling from bed during an incontinence change for 1 of 3 sampled residents for accidents. (R#6)
January 13, 2026Complaint inspection · 2 citations
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on Observation, record review, and interview it was determined that the facility failed to ensure that residents were free of significant medication errors as evidenced by facility staff failing to administer medications in accordance with professional standards. This was evident for 1 (#5) of 8 resident reviewed for medication administration.
- D
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on medical record review and interview, facility nursing staff failed to follow a physician's order for an upper right quadrant ultrasound for a resident (Resident #6). This was evident for 1 of 7 residents reviewed during a complaint survey.
July 24, 2025Standard inspection, Complaint inspection · 30 citations
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of employee records and interview with facility staff, it was determined that the facility failed to 1) conduct annual performance reviews of Geriatric Nursing Assistants (GNAs) and 2) provide regular, in-service education based on the outcome of those individual performance reviews. This was evident for 5 (GNA #49, GNA #50, GNA #1, GNA #51, GNA #52) of 5 randomly selected GNAs' records reviewed during the facility's recertification survey.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interviews, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 2 of 3 nursing units observed during the recertification/complaint survey.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility reported incidents, record review, and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation and misappropriation of property within 24 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 8 (#120, #107, #117, #67, #81, #103, #104, #122) residents reviewed for 21 facility reported incidents during the recertification/complaint survey.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility reported incidents, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse and misappropriation of property were thoroughly investigated. This was evident for 7 (#120, #127, #117, #101, #81, #103, #126) of 21 residents reviewed for facility reported incidents during the recertification/complaint survey.
- E
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 medical record review and interview, it was determined the facility staff failed to hold care plan meetings to include the interdisciplinary team, resident and resident's representative for residents. This was evident for 5 (Resident #1, #4, #9, #67, and #75) of 64 residents reviewed during a recertification/complaint survey.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to provide treatment and care in accordance with professional standards of practice for residents (Resident #40, # 75, #106 and #113). This was evident for 4 of 64 residents reviewed during a recertification/complaint survey.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on medical record review, observation, and interview, it was determined the facility failed to 1) ensure that fall precautions were in place, per the physician's orders, for a resident with a history of falls from the bed, 2) follow the resident's smoking plan of care, and 3) provide supervision for residents requiring supervision while smoking. This was evident for 4 (Resident #4, #1, #83, and #97) of 64 residents reviewed during the recertification/complaint survey.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of complaints, medical record review, and staff interview, it was determined the facility failed to 1) provide timely medication to meet the needs of the residents, and 2) ensure that narcotic medications were consistently reconciled by two nurses at change of shift. This was evident for 3 (#67, #108, #111) of 64 residents reviewed, and 4 halls ([NAME], [NAME], [NAME], and [NAME]) of 4 halls of narcotic and controlled substance log binders reviewed for accuracy and completeness of controlled medication storage and documentation during the recertification/complaint survey.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on a tour of the kitchen, staff interview and observation, it was determined that the facility staff failed to 1) ensure proper disposal of foods no longer safe to consume, and 2) store food in accordance with professional standards for food service safety. This was evident for 2 out of 3 kitchen tours and observation of a nourishment room during the recertification/complaint survey.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of a complaint, observation of resident rooms, common shared areas, interviews, and documentation review, it was determined that the facility staff failed to 1)follow infection control practices and guidelines to prevent the development and transmission of infection and disease, 2) ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions during medication administration to resident with a Gastrostomy tube and post appropriate Enhanced Barrier Precautions (EBP) signage, 3) place order for contact precaution and care plan for a resident with an infectious disease, 4) place precaution order and signage on the door for EBP residents. This was evident on 3 of 3 hallways observed, 5 (Residents #11, #128, #12, #27, and #44) of 7 residents reviewed for Infection Control during the recertification/complaint survey.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations of restrooms for residents and visitors, a nursing station, a public shower room, and facility staff offices, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, visitors, and staff as identified. This was evident in 2 staff bathrooms observed on 2 nursing units, 2 of 2 shower rooms, and 2 staff offices observed during the recertification/complaint survey.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation during the initial tour of the facility and staff interviews, it was determined that the facility staff failed to ensure a resident had the call bell control by their side. This was evident for 2 (Resident #9 and #43) out of the 64 residents in the survey sample.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of Resident Council meeting minutes and interview with facility staff, it was determined that the facility failed to have an effective system in place to demonstrate their response and rationale for concerns identified by the Resident Council. This was found to be evident based on review of 4 months of Resident Council meeting minutes.
- D
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 medical record review and interview, it was determined the facility staff failed to notify a resident's representative (Resident #13 and #110) and a resident's physician (Resident #13) for a change in condition. This was evident for 2 of 64 residents reviewed during a recertification/complaint survey.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review, review of facility documentation and interview, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #104). This was evident for 1 of 64 residents reviewed during a recertification/complaint survey.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on review of a facility reported incident, medical records, controlled drug sheets, and interviews it was determined that the facility failed to ensure residents were free from misappropriation of narcotics. This was evident for 1 (#81) of 22 residents reviewed for facility reported incidents during the recertification/complaint survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#127, #111, #108) of 64 residents reviewed during the recertification/complaint survey.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to ensure 1) a baseline care plan was completed and 2) a summary, including a current list of medications, was provided to the resident. This was evident for 1 (Resident #101) out of 3 closed records reviewed during the facility's recertification survey.
- 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 clinical record review and staff interview it was determined that the facility staff failed to ensure a care plan was developed to address a resident's catheter use. This was evident for 1 (Resident #80) out 64 residents that were part of the survey sample.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on a review of resident medical records and interviews with facility staff, the facility failed to 1) address a significant weight loss, and 2) follow the recommendations of the Dietitian for a resident. This deficiency was evident in 2 (Resident #9 and #116) of 2 residents reviewed for nutrition during this recertification/complaint survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interviews, and medical record review, it was determined that facility staff failed to provide respiratory care to meet the needs of residents. This was evidenced by: absence of physician orders indicating the use of oxygen for residents, failure to maintain nasal cannulas in a sanitary manner, and failure to administer oxygen according to the prescribed settings. This was evident for three residents (#1, #3, and #13) reviewed for respiratory care during the recertification/complaint survey.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review, resident and staff interview, it was determined that the facility failed to 1) properly assess for pain, 2) have parameters for pain medications used for pain management, 3) provide nonpharmacological intervention for a resident's reported pain, 4) received PRN (as needed) pain medication according to the Physician order set parameters (a specific instruction given for administration of medication), and 5) failed to administer a scheduled pain medication according to a Physician order. This was evident for 2 (Resident #1 and # 2) out of 2 residents reviewed for pain during this recertification/complaint survey.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on clinical record review and staff interview it was determined that the nursing staff failed to monitor behavior of a resident. This was evident for 3 (Resident #3, #6, and #45) out of 64 residents assessed for behavior monitoring during this recertification/complaint survey.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure medications were held according to the physician orders. This was evident for 1 (Resident #43) out of 64 residents in the survey sample.
- 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, documentation review, and interview with resident and staff, it was determined that the facility staff failed to 1) properly store medication by leaving a narcotic medication on the bedside table in the resident's room, and 2) keep treatment carts locked when unattended and discard medications/biologicals when expired. This was evident for 1 (Resident # 40) of 29 residents bedroom areas observed, and 1 of 3 nursing units observed during random observations made during the recertification/complaint survey.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interviews, and medical record review, it was determined that the facility failed to arrange for dental services within a reasonable time frame following the dental consultant recommendation. This was evident for 1 of 2 residents (#45) selected for dental complaints during this recertification/complaint survey process.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 3 (Resident #67, #75, and #108) of 64 residents reviewed during an recertification/complaint survey.
- 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 medical record reviews and staff interviews, it was determined that the facility staff failed to ensure timely updates to the residents' hospice status. This was evident for 1 (Resident #9) of 2 residents reviewed for hospice care during this recertification/complaint survey.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to provide education regarding the risks versus benefits of the pneumonia vaccine. This was evident for 2 out of 5 residents (Resident #1 and #5) whose immunization records were reviewed during this recertification/complaint survey.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure residents' COVID-19 vaccination status was properly monitored. This was evident for one (Resident #5) of five residents whose COVID-19 vaccination records were reviewed during this recertification/complaint survey.
September 21, 2022Standard inspection · 21 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to provide reasonable accommodations for 1.) Resident #40 as evidenced by failing to have a language line communication system. The Language Line allows the Service Provider to access a translator by phone to communicate with people who speak a language other than English and 2). failed to ensure call bells were within reach of the Residents (#25 and #26). This was evident for 3 (Residents #40, #25 and #26) out of 66 residents reviewed during an annual recertification survey.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of Resident Council meeting minutes and interview with members of the resident council it was determined that the facility staff failed to consistently update the residents with responses to their concerns. This was evident for 6 out of the 18 months reviewed.
- E
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 clinical record review and staff interview it was determined that the facility staff failed to ensure that Advanced Directives were offered and/or available in the clinical record for 5 out of the 66 residents reviewed as part of the survey sample (Residents #16, #32, #41, #42, and #43).
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that residents' rooms were maintained in a homelike environment by failing to conduct routine assessments of the resident room and completing repairs when needed. This was found to be evident while touring the facility during the facility's annual Medicare/Medicaid survey.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the resident's responsible party and/or the Ombudsman. This was found to be evident for 5 out of 66 (Resident #27, #75, #14, #12 and #47) residents reviewed for a facility-initiated transfer during the investigation of the survey.
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a copy of the facility bed hold policy was provided to the resident's responsible party. This was evident for 2 (#12 and #47) out of the 66 residents in the survey sample.
- E
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 clinical record review and staff interview it was determined that the facility staff failed to ensure care plan meetings were held, failed to update care plans for residents and failed to ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the quarterly care plan meetings. This was evident for 5 (Resident #2, #16, #41, #7, and #27) out of 66 residents in the survey sample.
- 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 interviews with facility staff, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and resident interview it was determined that the facility staff failed to ensure a cord used to turn on/off a call light was in working condition to allow the residents a means of directly contacting staff. This was evident for 5 rooms (room [ROOM NUMBER], 17, 41, 56, and Resident #27's room) toured as part of the annual survey.
- D
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 medical record review and interview, it was determined the facility staff failed to notify the physician of a resident's abnormal radiology results in a timely manner (Resident #47). This was evident for 1 of 66 residents reviewed during an annual survey.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on a review of the facility's investigation of a facility reported incident and staff interview it was determined that the facility failed to protect a resident from abuse. (Resident #41). This was evident for 1 out of 17 residents selected for review for abuse during the annual survey process.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on medical record review, staff interview and review of facility statements, it was determined the facility staff failed to report an incident of alleged abuse to the Office of Health Care Quality (OHCQ) and local law enforcement as required (Resident #186). This was evident for 1 out of 17 residents reviewed for abuse during an annual survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #7 and #23). This was evident for 2 out of 66 residents selected for review during an annual survey.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan upon admission. This was evident for 1 of 6 (Resident #27) residents reviewed during the complaint investigations.
- 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 medical record review and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #38 and #32). This was evident for 2 out of 66 residents reviewed during an annual survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to document or assess the care for a peripherally inserted central catheter (PICC) line in accordance with generally accepted standards of nursing practice for Resident #235. This was evident in 1 of 66 residents selected for review during the annual survey process.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to follow physician's orders in the care of a resident (Resident #187). This was evident for 1 out of 66 residents reviewed during an annual survey.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for a resident (Resident #7). This is evident for 1 of 4 residents reviewed for pressure ulcers during an annual survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and staff interviews, the facility staff failed to ensure that a resident's environment was reasonably free of hazards (Resident #20 and # 133). This was evident for 2 of 66 residents reviewed during an annual survey.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and medicate Resident #63. This was evident for 1 of 66 residents selected for review of pain assessment during the annual survey.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in 1 of 1 survey results book posted in the facility.
Fire safety inspections
26 fire safety citations on file: 3 on July 17, 2026, 7 on July 24, 2025, 16 on September 21, 2022.
Every fire safety citation26 citations
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · July 17, 2026 · Not yet corrected
- D
Install properly constructed and protected linen or trash chutes.
K 541 · July 17, 2026 · Not yet corrected
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 17, 2026 · Not yet corrected
- 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 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · July 24, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 24, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · July 24, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 24, 2025 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · July 24, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 21, 2022 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 21, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 21, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 21, 2022 · 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 21, 2022 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · September 21, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 21, 2022 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 21, 2022 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · September 21, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · September 21, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 21, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 21, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · September 21, 2022 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · September 21, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · September 21, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · September 21, 2022 · Corrected (the home has a date of correction)