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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
9J
2K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
3E
2F
Potential for minimal harm
0A
0B
0C
July 30, 2025Standard inspection, Complaint inspection · 5 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on the policy review, observation, interview, and product information sheets, the facility failed to provide an environment free of accident hazards for 1of 4 common hallways (200 hall) when the facility left a bleach germicidal spray cleaner and a disinfectant spray easily accessible to residents on the 200 hall, and when unsecured sharps were observed in 5 of 52 (Resident #2, #75, #76, #88, and 90) resident rooms observed for accident hazards. There were 5 residents with wandering behaviors in the facility.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on policy review, resident fund statement review, medical record review, and interview, the facility failed to notify the resident and/or resident representative when the amount in the residents' account exceeded the eligibility limit for 4 of 37 residents (Resident #45, #59, #86, and #87) and when the facility failed to refund the resident's funds within 30 days of death or discharge for 1 of 1 sampled residents (Resident #103) reviewed for personal fund account statements.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on policy review, medical record review, and interview the facility failed to follow physician orders to meet professional standards of practice for 7 of 21 (Resident #3, #6, #7, #11, #12, #14 and #45) sampled residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure infection control practices were followed to prevent the spread of infection when 2 of 4 (Licensed Practical Nurse (LPN) B and D) staff failed to perform hand hygiene for 3 of 9 (Resident #1, #18 and #75) residents, 2 of 4 (LPN B and Registered Nurse (RN) C) nurses failed to clean reusable equipment between residents for 2 of 9 (Resident #18 and #45) during medication administration.
- 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 policy review, observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 2 of 53 (Resident #5, #46, #55, and #93) shared resident bathrooms, and for 2 of 53 (Resident #64, #76, and #92) shared resident rooms observed.
April 11, 2024Complaint inspection · 7 citations
- K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility policy review, www.hopkinsmedicine.org/health, Police Incident Report dated [DATE] review, facility investigation review, medical record review and interviews, the facility failed to ensure residents were free from abuse/sexual for 6 of 9 (Residents #3, #7, #9, #11, #14, and #15) sampled residents reviewed for abuse/neglect. On [DATE] during group activities Resident #11, who had a BIMS of 12, approached Resident #15, who had a BIMS of 4, began to rub across her shoulders and back, and then tried to kiss her. Resident #15 told Resident #11 to stop and pushed him away. Resident #11 then put some money on the table in front of Resident #15 and pushed it towards her while saying, If this isn't enough, let me know. On [DATE] Resident #11 approached Resident #15 during activities and pulled up his shirt and began rubbing his nipples. Resident #15 pushed him away from her. [...]
- K
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, (Named Glucometer- a device used to check blood sugar levels with the use of a blood sample) User's Guide review, Guidelines for General Use of (Named germicidal cloth) wipes used by the facility review, DME (Durable Medical Equipment) supplier recommendation letter review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with facility required cleansing wipes to prevent cross-contamination of bloodborne pathogens for 2 of 11 (Residents #17 and Resident #18) sampled residents reviewed for blood glucose monitoring. [...]
- 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 policy review, medical record review, and interview, the facility failed to notify and consult the Physician/Nurse Practitioner (NP) of a change in condition related to falls 1 of 6 (Resident #7) sampled residents reviewed for change in condition. On [DATE], Resident #7 had an unwitnessed fall and was found on the floor with his head under the bed. Resident #7 hit his head while being placed back in bed by staff. The Physician/NP was not notified of Resident #7's unwitnessed fall on [DATE], and on [DATE], Resident #7 experienced a change in mental status. The NP was notified on [DATE] (1 day after the change in mental status and 4 days after the unwitnessed fall) of Resident #7's change in condition and again, was not notified of the unwitnessed fall the resident sustained on [DATE]. [...]
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure the appropriate information for transfer or discharge was communicated to the receiving healthcare facility or provider for 1 of 3 residents (Resident #7) sampled residents reviewed. Resident #7 was transferred to Hospital #1 Emergency Department (ED) on 1/29/2024 for evaluation of a change in mental status. Facility nursing staff failed to communicate information related to Resident #7's unwitnessed fall on 1/25/2024 on the written report to Hospital #1.
- 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 facility policy review, medical record review, and interview, the facility failed to implement a comprehensive person-centered care plan for 3 (Resident #3, Resident #10, and Resident #15) of 20 residents reviewed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to assess after a fall, care for a resident after a fall, and monitor after a fall for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. There were no immediate interventions documented following the fall. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that is free from accident hazards for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. LPN G documented staff (CNA AA and CNA CC) assisted Resident #7 off the floor and Resident #7 hit his head on the bed. CNA AA and CNA CC then placed Resident #7 back in bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. [...]
December 15, 2021Standard inspection · 10 citations
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on policy review, documentation review, and interview, the facility failed to provide a nourishing snack at bedtime between the evening and breakfast meal which was 15 hours affecting 84 of the 90 resident census.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observations and interview, the facility failed to maintain dietary equipment in a sanitary manner for 2 of 2 observations in the dietary department.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to handle soiled Transmission Based Precaution linen in a manner to prevent spread of infection and the facility failed to ensure oxygen tubing was kept off the floor for Residents #70 and #79.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observations and interviews, the facility failed to ensure positioning needs were in accordance with professional standards of practice for 1 of 5 sampled residents (Resident #45) reviewed. The facility failed to follow Physician's Orders for 1 of 10 residents (Resident #381) reviewed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to change the humidifier bottle weekly for 2 of 15 sampled residents (Resident #29 and Resident #38) and failed to change oxygen tubing weekly for 3 of 15 sampled residents (Resident #29, Resident #38, and Resident #70) and failed to store a nebulizer mask in a safe and sanitary manner for 1 of 15 sampled residents (Resident #79) reviewed receiving respiratory treatments.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on facility policy review, facility documentation review, and interview, the facility failed to have eight hours of consecutive Registered Nurse (RN) coverage for four days out of eighteen months reviewed.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on Manufacturer Guidelines, medical record review, and interviews, the facility failed to perform an Abnormal Involuntary Movement Assessment (AIMS) for the use of Reglan for 1 of 6 sampled residents (Resident #45) reviewed for unneccessary medications.
- 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 facility policy review, medical record review, and interview, the facility failed to provide a duration for the use of PRN (as needed) psychotropic (chemical substance that alters perception, mood, consciousness, cognition or behavior) medication for 3 of 61 sampled residents (#28, #32, and #36) reviewed for unnecessary medications. Review of the facility policy Use of Psychotropic Drugs Policy, dated 5/1/2017 and revised on 6/8/2021, revealed .PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [...]
- 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 facility policy review, observations, and interviews, the facility failed to assure drugs and biologicals were properly labeled, were stored in sanitary conditions, were not expired and were stored in a locked compartment for 1 of 5 medication carts. Review of the facility policy titled, Medication Administration: [...]
- 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 facility policy review, medical record review, observation, and interview, the facility failed to provide a sanitary environment for 2 of 6 sampled residents (Resident #45 and #74) receiving enteral feeding. Review of the facility policy titled, Housekeeping-Cleaning and Disinfection, dated 11/30/2018 and revised 7/12/2021, revealed, .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule to keep surfaces clean and dust free .Horizontal surfaces with infrequent hand contact .in routine resident-care areas should be cleaned: a. On a regular basis b. [...]
March 10, 2020Standard inspection · 10 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interview the facility failed to ensure 1 of 38 residents (Resident #33) was free from abuse placing the resident in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #33 sustained a left humerus (long bone that extends from the shoulder to the elbow) fracture during an attempted transfer, without a mechanical lift, on 10/22/2019. [...]
- J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to report an abuse allegation to the State Survey Agency for 1 of 38 residents (Resident #33) reviewed or abuse. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to investigate an abuse allegation for 1 of 38 residents (Resident #33) reviewed for abuse. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-610 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.
- J
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 facility policy review, medical record review and interview, the facility failed to develop and implement a person centered care plan with interventions related to blood sugar monitoring and tube feeding residual to prevent hypoglycemia for 1 of 38 residents (Resident #77) reviewed for implementation of care plans placing Resident #77 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #77 became unresponsive, hypoglycemic, and required emergent hospitalization. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 3/5/2020 at 3:50 PM in the Administrators office. The facility was cited Immediate Jeopardy at F-656. [...]
- J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to ensure a resident's Advance Directive preference was accurately reflected in the medical record for 2 of 91 residents (Resident #49 and #6) reviewed for Advance Directives, placing the residents in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure to follow their procedures for processing Advance Directives, had the potential for staff not intervening with life saving measures, (CPR [Cardiopulmonary Resuscitation]) for Resident #49 when Resident #49 wanted CPR and intervening with life saving measures (CPR) for Resident #6, when Resident #6 wanted to be a DNR [Do Not Resuscitate]. [...]
- J
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure the prescribed tube feeding formula was available for 1 of 5 residents (Resident #77) reviewed for tube feedings when Resident #77's prescribed tube feeding was substituted with a tube feeding formula that required an increase in rate to equal the nutritional value. The increase in the tube feeding rate resulted in Resident #77's increased residuals, tube feedings held frequently, and rate had to be decreased, so the resident was not provided the required caloric intake to sustain him in his severely malnourished state, which resulted in unresponsiveness, hypoglycemia, and emergent hospitalization. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. [...]
- J
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on facility policy review, facility documentation review, medical record review, and interview facility administration failed to recognize, report, and investigate an abuse allegation for 1 resident (Resident #33) reviewed for reporting an abuse allegation and failed to ensure the residents' Physician Orders for Scope of Treatment (POST) forms for 2 residents (Resident #6 and #49) reviewed for Advance Directives were accurately reflected in the resident's Electronic Medical Record (EMR) regarding the residents' Code status preferences, and failed to implement a Comprehensive care plan for hypoglycemia for 1 of 38 residents (Resident #77) reviewed for Comprehensive care plans. [...]
- J
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the QAPI committee failed to identify deficient practice for investigating allegations of abuse for 1 of 38 residents (Resident #33) reviewed for abuse; failed to identify no person centered care plan was implemented for 1 of 38 residents (Resident #77) reviewed for care plan implementation and interventions; and failed to identify the prescribed tube feeding formula was unavailable for 1 of 5 residents (Resident #77) reviewed for tube feedings which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). [...]
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on medical record review, observation and interview, the facility failed to change, date, and initial a PICC (peripherally inserted central catheter) (a form of intravenous access that can be used for prolonged period of time) line dressing for 3 (Resident #58, #68, and #135) of 5 residents reviewed with PICC lines.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to maintain dignity for 1 of 5 residents (Resident #18) reviewed who required an indwelling urinary catheter.
Fire safety inspections
10 fire safety citations on file: 8 on July 30, 2025, 1 on December 15, 2021, 1 on March 10, 2020.
Every fire safety citation10 citations
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 30, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 30, 2025 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · July 30, 2025 · Corrected (the home has a date of correction)
- D
Establish policies and procedures including evacuation.
E 20 · July 30, 2025 · Corrected (the home has a date of correction)
- D
Conduct testing and exercise requirements.
E 39 · July 30, 2025 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · July 30, 2025 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 30, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · July 30, 2025 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · December 15, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 10, 2020 · Corrected (the home has a date of correction)