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 52 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
21D
14E
5F
Potential for minimal harm
0A
9B
1C
December 30, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was readmitted to the Facility after a hospitalization and who required follow up appointments one week post discharge with Cardiology and Gastrointestinal providers, the Facility failed to ensure he/she was provided services that met professional standards of practice when arraignments for the follow-up appointments were not made or scheduled by nursing. Findings Include:Resident #1 was admitted to the Facility in October 2025, diagnoses included gastrointestinal hemorrhage, anemia, atrial fibrillation (irregular heartbeat), hypertension, anoxic brain damage, and seizure disorder. [...]
May 14, 2025Complaint inspection · 4 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 records reviewed and interviews for one of three sampled residents (Resident #1), whose Health Care Agent (HCA, Family Member #1) was very involved in his/her care, the Facility failed to ensure staff promptly notified Family Member #1 of a change in Resident #1's status, when on 04/25/25, he/she fell while working with Occupational Therapy (OT).
- 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 records reviewed and interviews for one of three sampled residents, (Resident #1), the facility failed to ensure that upon admission, that nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.
- 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 records reviewed and interviews for one of three sampled residents (Resident # 1), who upon admission required a therapeutic diet in relation to diabetes mellitus, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals, and outcomes that addressed his/her person-centered nutritional needs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had been assessed as requiring nutritional interventions for wound care, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality, when recommendations made by the Registered Dietician (RD) for Resident #1, were not followed up on timely by nursing.
March 7, 2025Standard inspection · 13 citations
- F
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 interviews and observations, the facility failed to ensure grievance forms were available in resident care and public areas so residents and/or visitors were able to access forms without requesting staff assistance.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to ensure a resident at risk for skin breakdown with a wound received necessary treatment and services to promote healing for one Resident (#59), out of a total sample of 18 residents. Specifically, the facility failed to complete weekly skin checks, to investigate wounds caused by injury/trauma, and to follow wound physician's recommendations and accurately implement care and treatment of a non-pressure wound to the Resident's left knee, heel, and shin.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and to promote healing for two Residents (#2 and #59), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #2, to perform weekly skin assessments and/or monitor his/her skin until he/she developed an unstageable pressure ulcer on the left heel, and an unstageable pressure area on the left calf. The calf pressure wound required debridement and was eventually assessed as a stage 3 pressure area (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed); and 2. [...]
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for nine Residents (#59, #67 #18, #24, #27, #31, #64, #68, #77 and #2 ), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #59, Urology consultation progress notes/office visit notes were part of the medical record; 2. For Residents #18, # 24, #27, #31, #64, #68, and #77, the Medication Administration Record (MAR) was accurate, documenting on 3/4/25 and 3/5/25, the residents received their nutritional supplements when they remained in the refrigerators on their respective units; and 3. For Resident #2, the MAR was accurate, documenting the Resident was being administered off-loading booties when they were not available to the Resident.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for 10 Residents (#65, #31, #3, #9, #26, #28, #40, #72, #17, and #21). Specifically, the facility failed: 1. For Residents #65, #31, #3, #9, #26, and #28, to initiate Transmission Based Precautions (TBP) specifically Droplet Precautions, as indicated for suspected influenza while diagnostic testing was pending; 2. For Residents #40 and #72, to ensure staff implemented appropriate use of personal protective equipment (PPE) prior to entering rooms of Residents on TBP (Droplet Precautions); 3. [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for bruises of unknown origin for two Residents (#2 and #12), in a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #2, to ensure a large bruise of unknown origin on the right side of the Resident's head was fully investigated to prevent potential further injury; and 2. Resident #12, to ensure bruises to the left elbow and wrist were fully investigated to prevent potential further injury.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report bruises of unknown origin to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS-a web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) as required for two Residents (#2 and #12), in a total sample of 18 residents. Specifically, the facility failed to report bruises of unknown origin within the required timeframe to the State Survey Agency for: 1. Resident #2's large bruise to the right side of the head; and 2. Resident #12's bruises to the left elbow and hand.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to fully investigate bruises of unknown origin for two Residents (#2 and #12), in a total sample of 18 residents. Specifically, the facility failed to investigate: 1. Resident #2's large bruise to the right side of the head; and 2. Resident #12's bruises to the left elbow.
- 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, and interview, the facility failed to provide treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body), for one Resident (#26), out of a total sample of 18 residents. Specifically, the facility failed to ensure the physician's orders were followed and the correct size indwelling catheter balloon was implemented for Resident #26.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for two Residents (#61, #29) with a history of trauma, out of a total sample of 18 residents.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) of an anticoagulant agent (blood thinner) prescribed for one Resident (#12), out of a total sample of 18 residents.
- 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 interview, the facility failed to ensure a Notice of Transfer/Discharge was issued to one Resident (#69), out of a total sample of 18 residents and one discharged Resident (#80), out of a total sample of three discharged residents.
- 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 a Bed Hold Policy Notice was issued upon transfer to the hospital for one Resident (#69), out of a sample of 18 residents, and one discharged Resident (#80), out of a total sample of three discharged residents.
July 15, 2024Complaint inspection · 1 citation
- G
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, and on 6/23/24 during the overnight shift had been heard calling out for help and was found on the floor by two Certified Nurse Aides (CNAs) after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of practice, when although Nurse #1 went to Resident #1's room with the two CNA's to check him/her, after a brief assessment Nurse #1 assisted the CNA's with lifting him/her off the floor and putting him/her back in to bed. [...]
January 18, 2024Standard inspection · 27 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management for one Resident (#53), out of a total sample of 20 residents, when the facility was unable to reach the Resident's primary care physician for new pain management orders based on Hospice recommendations, resulting in the Resident suffering very severe pain of 7/8 on a scale of 1-10 with 10 being the worst pain for more than 24 hours after the Hospice recommendation was made.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility.
- F
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on review of the Facility Assessment, interview, and staff education record review, for 7 out of 8 direct care employees reviewed, the facility failed to ensure that the training on effective communication was included as mandatory training for direct care staff per facility assessment.
- F
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on review of the Quality Assurance and Performance Improvement (QAPI) program, interview, and staff education record review, for seven out of eight direct care employees reviewed, the facility failed to ensure that the training on the facility's Quality Assurance Performance Improvement (QAPI) program was included as part of the mandatory training for all staff per facility policy.
- F
Provide training in compliance and ethics.
Inspectors wroteBased on review of the Facility Assessment, interview, and staff education record review, for eight out of eight employee records reviewed, the facility failed to ensure that the training on compliance and ethics was included as part of the mandatory training for all staff per facility assessesment.
- E
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 observations, interviews, and records reviewed for four Residents (#27, #72, #28, and #41), of 20 sampled residents, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented. Specifically, the facility failed to ensure: 1. For Resident #27, a care plan was developed to address the Resident's history of Post-Traumatic Stress Disorder (PTSD, occurs in some individuals who have encountered a shocking, scary, or dangerous situation. Symptoms usually begin early, within three months of the traumatic incident, but sometimes they begin years afterward); 2. For Resident #72, his/her fall care plan was updated after a fall and was inclusive of new interventions; 3. For Resident #28, a care plan was developed to address the Resident's recent history of suicidal ideation; and 4. [...]
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on records reviewed and interviews, for one Resident (#22), of 20 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure for four Residents (#11, #28, #71, and #72), out of a total sample of 18 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure: 1. For Resident #11, the use of antipsychotic medication was managed and monitored for movement disorders to promote the Resident's highest practicable mental, physical, and psychosocial well-being; 2. For Resident #28, that psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; 3. For Resident #71, that psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; and 4. For Resident #72, a. [...]
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Arbitration Agreement presented to residents as part of the admission packet included the required information for one Resident (#46), out of a sample of one record reviewed. Specifically, the facility failed to ensure the Resident had a full thirty days to rescind the Arbitration Agreement after signing it as required.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on one (West unit) of two units.
- E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interview, the facility failed to implement and maintain and effective training program per the facility assessment for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident.
- E
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Inspectors wroteBased on review of the Facility Assessment, interview, and staff education record review, for four employees (Nurse #4, Nurse #6, Nurse #7, and Certified Nursing Assistant (CNA) #4), out of eight employees reviewed, the facility failed to ensure that the training on resident rights was included as mandatory training for all staff per facility assessment.
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on review of the Facility Assessment, interview, and staff education record review, for three employees (Nurse #4, Nurse #6, and Certified Nursing Assistant (CNA) #4) out of eight employees reviewed, the facility failed to ensure that the training on abuse, neglect, and exploitation was included as mandatory training for all staff per facility assessment.
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on review of the Facility Assessment, interview, and staff education record review, for six out of eight direct care employees reviewed, the facility failed to ensure that the training on behavioral health was included as part of the mandatory training for all staff.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, interviews, records reviewed, and review of the facility policies for two Residents (#22 and #41), of 20 sampled residents, the facility failed to provide care and services consistent with professional standards of practice. Specifically the facility failed: 1. For Resident #22, to communicate to the physician and timely implement recommendations made by a consulting hospice nurse; and 2. For Resident #41, to follow their policy and fully investigate a fall to analyze the vulnerabilities and consider interventions to mitigate the risk of future falls.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure proper care and treatment of a midline catheter (long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medication into the bloodstream) device in accordance with professional standards of practice for one Resident (#56), out of a total sample of 20 residents. Specifically, the facility failed to flush the midline to prevent blockages and change the midline dressing per physician's orders.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on records reviewed, interviews, and policy review, for one Resident (#27) with a history of trauma, of 20 sampled residents, the facility failed to ensure he/she received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to assess the Resident and identify triggers of trauma to prevent potential re-traumatization.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observations, interviews, and records reviewed, for two Residents (#75 and #279), of 20 sampled residents, the facility failed to provide specialized rehabilitative services, specifically speech-language pathology services, as required in the resident's comprehensive plan of care.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for one Resident (#28), out of a total sample of 13 residents. Specifically, the facility failed to ensure staff accurately and completely documented the presence of signs and symptoms of infection of the Resident's port-a-cath (device that is usually placed under the skin in the right side of the chest. It is attached to a catheter (a thin, flexible tube that is threaded into a large vein above the right side of the heart called the superior vena cava) to deliver medication.
- C
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS-State agency reporting system), the facility failed to provide written notice to the State agency when a change in the facility's Director of Nursing (DON) occurred.
- B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review, interview, and the Beneficiary Protection Notification Review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two Residents (#180 and #181), out of three resident records reviewed. Specifically, the facility failed: 1. For Resident #180, to issue the NOMNC and the SNF ABN notice; and 2. For Resident #181, to issue the NOMNC notice.
- 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, policy review, and interview, the facility failed to ensure written notice for transfer and discharge was provided to Residents and/or Resident Representatives prior to hospital transfers for two Residents (#56 and #72), out of a total sample of 20 residents.
- 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, policy review, and interviews, the facility failed to provide written notification of the bed hold policy to one Resident (#56) prior to transfer to the hospital, out of a total sample of 20 residents.
- B
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and records reviewed, for two Residents (#43 and #17), of six residents reviewed, the facility failed to conduct annual comprehensive assessments through completion of Minimum Data Set (MDS) assessments as required.
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and records reviewed, for five Residents (#69, #40, #23, #8, and #53), of six residents reviewed, the facility failed to conduct quarterly assessments through completion of Minimum Data Set (MDS) assessments as required.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for two Residents (#28 and #76), in a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #28, to ensure the MDS accurately reflected his/her cognitive status; and 2. For Resident #76, to ensure the MDS accurately reflected his/her discharge status.
- B
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on interview and review of the Arbitration Agreement, the facility failed to ensure their arbitration agreement specifically provides for the selection of a venue that is convenient to both parties as required.
December 7, 2021Standard inspection · 6 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, documentation review, policy review, and interview, the facility 1. Failed to implement transmission-based precautions (TBP) for a newly admitted Resident (#268) and educate the Resident's family on TBP, per the facility's policy, to help prevent the potential spread of infection throughout the facility; and 2. Failed to have an ongoing infection control and surveillance program that included consistent tracking, identifying, and monitoring of all potential or actual infections within the facility.
- 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 record review and interviews, the facility failed to notify the physician and the Healthcare Proxy (HCP) when a resident returned to the facility with a new trauma pressure injury for one Resident (#35), out of a total sample of 17 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure that professional standards for medication administration via a gastrostomy tube (GT) were met for one Resident (#9), out of a total sample of 17 residents. Specifically, the facility failed to ensure staff 1. Checked the GT for placement per the facility's policy; and 2. Flushed the GT with the proper amount of water, per the physician's order.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews, the facility failed to follow their policy by not immediately documenting the condition of a new trauma pressure injury the resident received while out of the facility at a medical appointment. In addition, they failed to notify and obtain treatment orders from the physician to start providing immediate care to the trauma pressure injury for one Resident (#35), out of a total sample of 17 residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure professional standards were followed for residents receiving dialysis services, through ongoing communication and collaboration with the dialysis facility for two Residents (#55 and #38), out of two total residents receiving dialysis.
- 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 interview, record review, and policy review, the facility failed for one Resident (#66), out of a total sample of 17 residents, to have documented evidence of a clinical rationale for the as needed extended use of a psychotropic medication.
Fire safety inspections
6 fire safety citations on file: 1 on March 7, 2025, 2 on January 18, 2024, 3 on December 7, 2021.
Every fire safety citation6 citations
- D
Install properly constructed and protected linen or trash chutes.
K 541 · March 7, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 18, 2024 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · January 18, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · December 7, 2021 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 7, 2021 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · December 7, 2021 · Corrected (the home has a date of correction)