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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
1L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
4E
1F
Potential for minimal harm
0A
3B
1C
August 28, 2025Standard inspection · 4 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to afford the resident the right to participate in the care planning process for 2 of 2 residents reviewed for care plans (Resident #31, and Resident #21).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to maintain safety for a severely cognitively impaired resident in a wheelchair when the Activities Director was assisting residents out the double doors at the front entrance of the facility to smoke. After assisting Resident #9 outside, the Activities Director failed to lock the brakes of Resident #9's wheelchair and Resident #9 rolled down the pavement in front of the facility approximately 31 feet and fell out of her wheelchair landing on her left side. Resident #9 sustained skin tears to the left elbow and left AKA (above the knee amputation) stump. Resident #9 also sustained abrasions to the chin, left cheek, lips, and the bridge of the nose with visible bleeding from the nostrils. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #9).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on record review, observations, and interviews with resident and staff, the facility failed to post cautionary signs for oxygen in use for 1 of 3 residents reviewed for respiratory care (Resident #28).
- B
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to provide 1 of 3 residents with quarterly statements of their personal trust fund account managed by the facility (Resident #21).
July 11, 2024Standard inspection · 5 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 observations and interviews, the facility failed to label a container of thickened juice with an open date, discard expired milk, clean grease off the burner valve knobs and burner grates of the stove. Additionally, 3 of 3 dietary workers failed to wear beard coverings. These practices had the potential to affect food served to residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on record review, observations, resident, and staff interviews, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for medication at the bedside (Resident #32).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to maintain a safe environment by storing a chemical disinfectant cleanser spray and a handheld hair dryer with the cord hanging over a mounted power strip for 1 of 1 shower rooms observed. The shower room door was propped open and unlocked when it should have been closed and locked.
- C
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on resident and staff interviews, the facility failed to provide mail delivery to the residents on Saturdays for 7 of 7 (Resident #5, #13, #15, #17, #32, #36, and #40) residents interviewed in resident council.
- B
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 staff interviews, the facility failed to maintain lighting and walls in good repair for 2 of 2 areas (resident room [ROOM NUMBER] and nurse's desk) when reviewed for environment.
March 29, 2023Standard inspection · 7 citations
- L
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review, Police Department Detective, resident and staff interviews the facility failed to implement their abuse policies and procedures by failing to immediately initiate preventative and protective measures to safeguard all residents from exploitation and misappropriation of property when the facility became aware of an allegation of the Social Services Coordinator exploiting 2 residents at the Assisted Living Facility (ALF) operated by the same company and on the same campus as the skilled nursing facility (SNF). There was a high likelihood of misappropriation of property and/or exploitation leading to the loss of financial resources and irreplaceable personal belongings for all 45 residents who resided in the SNF. [...]
- 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, staff interviews and record review the facility failed to date thawing food items in one of one walk-in refrigerator when they were removed from the freezer. This practice had the potential to affect food served to residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on record reviews, observation and staff interviews the facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey of 10/29/2021 in the area of kitchen sanitation, food procurement, storage, preparation and service and cited during the recertification survey of 3/29/23. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. This tag is cross referred to: F812-Based on observation, staff interviews and record review the facility failed to date thawing food items in the walk-in refrigerator when they were removed from the freezer. This practice had the potential to affect food served to residents. [...]
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and staff interviews, the facility failed to include documentation in the medical record education regarding the benefits and potential side effects of the Influenza and Pneumococcal immunization, and if residents received the Influenza or Pneumococcal immunization or did not receive the Influenza Pneumococcal immunization due to medical contraindication or refusal for 4 of 5 residents reviewed for infection control (Resident #149, #11, #42, and #34).
- E
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 the facility failed to include the status for COVID-19 vaccination in the medical record, failed to include education regarding the benefits or potential side effects of the COVID-19 vaccination, and failed to document COVID-19 vaccination declinations for 3 of 5 resident reviewed for infection control (Resident #11, #42, #149).
- 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 record review and staff interview the facility failed to develop a comprehensive care plan for 2 of 2 residents reviewed for Level II Preadmission Screening and Resident Review (PASRR) (Resident #6 and Resident #39).
- B
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 Record review and staff interviews the facility failed to provide a notice of transfer/discharge to the Resident or the Office of the State Long Term Care Ombudsman when the resident discharged from the facility to the hospital for 1 of 1 resident reviewed for hospitalization (Resident # 35).
Fire safety inspections
16 fire safety citations on file: 8 on July 11, 2024, 7 on March 29, 2023, 1 on October 29, 2021.
Every fire safety citation16 citations
- D
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 11, 2024 · Corrected (the home has a date of correction)
- 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 11, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 11, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 11, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 29, 2023 · Corrected (the home has a date of correction)
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · March 29, 2023 · Corrected (the home has a date of correction)
- D
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · March 29, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 29, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 29, 2023 · 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 · March 29, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 29, 2023 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 29, 2021 · Corrected (the home has a date of correction)