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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
16D
3E
1F
Potential for minimal harm
0A
2B
1C
April 28, 2026Standard inspection · 4 citations
- 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 records reviewed and interviews, the facility failed to ensure newly hired employees' records contained evidence of the 2025-2026 COVID-19 vaccination for four employees (Certified Nursing Assistant [CNA] #5, Dietary Staff #1, Housekeeping Staff #1, Nurse #5), placing staff and residents at an increased risk of becoming infected with Coronavirus disease (COVID-19: an infection caused by the SARS-CoV-2 virus), out of a total of five newly hired employees records reviewed. Specifically, the facility failed to:Ensure the employees' records contained evidence of the 2025-2026 COVID-19 vaccination, or that the newly hired employees were offered the most up-to-date (2025-2026) COVID-19 vaccine or were provided information on obtaining the COVID-19 vaccine, when she/he was eligible. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide reasonable accommodation pertaining to a bed for one Resident (#70) out of a total sample size of 16 residents. Specifically, for Resident #70, the facility failed to provide the option of a bed extender to prevent his/her lower extremities from hitting the wooden footboard, when the Resident was admitted with lower extremity cellulitis, an ankle sprain and a right heel deep tissue injury (DTI), placing him/her at risk for further lower extremity injury.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide care and services that met professional standards of practice relative to the administration and storage of medications for two Residents (#44 and #34), out of a total sample of 16 residents. Specifically, For Resident #44, the facility failed to maintain professional standards of practice during the administration of medications, when medications were left unattended by the Nurse on 4/26/26 and 4/28/26 for the Resident to administer independently when the Resident had a preference and consented to have the Nurse administer medications on 3/19/26 and was not assessed by the facility staff for the ability to safely self-administer medications. [...]
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure devices used to treat a decrease in range of motion (ROM) due to contractures and prevent further reduction or worsening of contractures were implemented as ordered by the Physician, for one Resident (#34), out of a total sample of 16 residents. Specifically, the facility failed to ensure the following devices were implemented as recommended by the Occupational Therapist (OT) and as ordered by the Physician increasing the potential for decreased range of motion, worsening contractures, pain, and impaired skin integrity:-A soft sling to be utilized during the day shift (7:00 A.M. [...]
February 18, 2025Standard inspection · 9 citations
- 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 observation, interview, and record review, the facility failed to notify the Physician/Physician Assistant (PA) of changes in condition for two Residents (#35 and #58) out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #35, notify the Physician/ PA timely of significant weight loss experienced by the Resident. 2. For Resident #58, ensure the Physician/PA was notified when the Resident had a significant weight change and continued significant weight decline.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview, and record review, the facility failed to ensure that Significant Change in Status Minimum Data Set [MDS] Assessments (SCSA) was completed for one Resident (#54) out of a total sample of 17 residents. Specifically, for Resident #54, the facility failed to ensure that a SCSA was completed when the Resident had a decline in activities of daily living (ADLs) and developed a new pressure ulcer.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, and record review, the facility failed to follow professional standards of practice relative to administering medication for one Resident (#42) out of a total sample of 17 residents. Specifically, for Resident #42, the facility failed to ensure that prescribed Insulin (medication used to treat diabetes) was administered within one hour before or one hour after the ordered time.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#35) out of a total sample of 17 residents. Specifically, for Resident #35, the facility failed to address significant weight loss and implement nutritional interventions when the Resident was identified to have greater than 10 percent (%) weight loss.
- 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 that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for one Resident (#214), of five applicable residents reviewed for unnecessary medications, out of a total sample of 17 residents.
- 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, and interview, the facility failed to provide continuity of care related to Hospice Services for one Resident (#42) out of a total sample of 17 residents. Specifically, for Resident #42, the facility failed to: -designate a member of the interdisciplinary team (IDT) responsible for working with Hospice Representatives to coordinate care provided by the facility staff and Hospice staff. -obtain the most recent Hospice Plan of Care and ensure that it was readily available.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that infection control practices were implemented to prevent the spread of infection on two Units (North Unit and [NAME] Unit) of two units observed. Specifically, the facility failed to: 1. For Resident #164 who resided on the North Unit, ensure that staff utilized proper Enhanced Barrier Precautions (EBP - set of infection control practices that uses Personal Protective Equipment (PPE) such as gowns and gloves to reduce the spread of multidrug resistant organism to residents who are at risk due to having a wound or indwelling medical device). 2. [...]
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, and interview, the facility failed to ensure that patient care equipment was maintained in a safe operating condition for one Resident (#3) out of a total sample of 17 residents. Specifically, for Resident #3, the facility failed to ensure that his/her wheelchair was maintained in safe condition when the left cushioned armrest of the Resident's wheelchair was missing leaving a metal bar and exposed screw and placing the Resident at risk of injury.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#35) out of a total sample of 17 residents. Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to weight loss for Resident #35.
February 28, 2024Standard inspection · 10 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, interview and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility staff failed to: 1a. Ensure kitchen cleanliness and store and prepare food in the main kitchen area in a manner that would prevent contamination and food-borne illnesses. 1b. Ensure food was stored in a manner to prevent food-borne illnesses in two out of two unit-based kitchen areas. 2. Ensure that a process was in place to safely reheat food and beverages for the residents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations and interviews, the facility failed to provide a resident environment that was free from potential hazards on one Unit (North Unit) out of two Units observed. Specifically, the facility staff failed to ensure that smoking materials were stored in a secured location, that was out of sight and not accessible to the residents.
- E
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 observations, interviews, and policy review, the facility failed to ensure medications and medical supplies were stored in a secure manner on two Units (North Unit and [NAME] Unit) out of two units observed and the main hallway of the facility. Specifically, the facility staff failed to ensure that: 1. Two treatment carts and one medication/medical supply storage cart were locked and not accessible to residents, non-authorized staff and visitors. 2. A medication storage closet located on the main hallway of the facility was locked.
- 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, interview and record review, the facility failed to develop a care plan for one Resident (#28) and implement the plan of care for two Residents (#41 and #57) out of a total sample of 15 residents. Specifically, the facility staff failed to: 1. Develop a care plan relative to monitoring the side effects of an anticoagulant medication (medication used to thin the blood) for Resident #28. 2. Obtain laboratory testing relative to anticonvulsant medication (medication used to control seizure activity) monitoring as ordered for Resident #41. 3. Perform fingerstick blood sugar (FSBS) monitoring (used to measure the amount of glucose in the blood) as ordered for Resident #57.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review, policy and interview, the facility failed to provide care and services for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#53) out of a total sample of 15 residents. Specifically, the facility staff failed to verify the correct size indwelling urinary catheter as ordered by the Physician and ensure the verified size catheter was in place for Resident #53, to prevent catheter related complications.
- D
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 observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for one Resident (#26) out of a total sample of 15 residents. Specifically, the facility staff failed to verify proper placement of a G-tube every shift as ordered by the Physician to prevent complications of enteral (passing through the gastrointestinal [GI] tract) feeding.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that an accurate medication reconciliation was completed upon admission to the facility from a hospitalization for one Resident (#28) out of a total sample of 15 residents. Specifically, the facility staff failed to: -For Resident #28, ensure that Lasix (a medication used to rid the body of extra fluid) medication was not re-started when the Resident was re-admitted to the facility following a hospital stay with a diagnosis and Physician documentation that indicated the medication should be held (not administered).
- 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 interview and record review, the facility failed to ensure one Resident (#49) out of a total sample of 15 residents, received the recommended treatment to address his/her mental health conditions. Specifically, the facility staff failed to ensure that recommendations made by the Psychiatric Nurse Practitioner (NP) for medication changes were reviewed by the Resident's attending Physician and implemented.
- C
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 interview, the facility failed to ensure that the Resident and/or Resident Representative was notified in writing of a transfer or discharge and that a representative in the Office of the State Long Term Care Ombudsman was also notified for five Residents (#41, #39, #52, #46, and #57) out of six applicable residents, out of a total sample of 15 residents. Specifically, the facility staff failed to ensure: 1. For Resident #41, that the Resident and/or Resident Representative was notified in writing, and the reason given for a transfer or discharge. 2. that the Office of the State Long Term Care Ombudsman was notified of the transfer/discharges for Residents #41, #46, #57, #39, and #52.
- B
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 record review and interview, the facility failed to ensure the Bed-Hold Policy was provided at the time of transfer to a hospital or shortly thereafter to one Resident (#41) and/or the Resident's Representative, out of a total sample of 15 residents.
September 28, 2023Complaint inspection · 2 citations
- G
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, records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls and who required assistance of two staff members with the use of a mechanical lift for safe transfers, the Facility failed to ensure staff consistently implemented and followed interventions from his/her plan of care related to his/her individual care needs related to transfers. On 09/04/23 during the day shift, a Certified Nurse Aide transferred Resident #1 out of bed, alone, and without a mechanical lift, resulting in him/her being lowered to the floor. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls, and who required extensive assistance from two staff members with the use of a mechanical lift during transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive device during a transfer to maintain his/her safety in an effort to prevent an incident and/or accident resulting in an injury. On 09/04/23, during the day shift, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without a mechanical lift and without a second staff member present to assist her, Resident #1's knees buckled, and she lowered him/her to the floor. [...]
Fire safety inspections
15 fire safety citations on file: 10 on April 28, 2026, 2 on February 18, 2025, 3 on February 28, 2024.
Every fire safety citation15 citations
- F
Include a process for Emergency Preparedness collaboration.
E 9 · April 28, 2026 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · April 28, 2026 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · April 28, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 28, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · April 28, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 28, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 28, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 28, 2026 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 28, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 28, 2026 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 18, 2025 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 18, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 28, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · February 28, 2024 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · February 28, 2024 · Corrected (the home has a date of correction)