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
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
8E
1F
Potential for minimal harm
0A
2B
0C
June 9, 2026Complaint inspection · 2 citations
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of opioid dependency and alcohol use disorder, the facility failed to ensure supportive services to maintain his/her sobriety were offered and available.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete, accurate, and accessible medical records, when his/her psychiatric service progress notes were not readily accessible and not included in his/her medical record.
April 21, 2026Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and records reviewed, for one of three sampled residents (Resident #1), who resided on a secured unit, had a guardianship in place, and whose care plan indicated he/she was to remain within the Facility unless supervised, the Facility failed to ensure they provided an adequate level of staff supervision to maintain his/her safety and prevent an incident of elopement.
April 14, 2026Standard inspection · 4 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interviews, and record reviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN - notice issued to beneficiaries so they may decide if they wish to continue receiving skilled services that may not be paid for by Medicare and assume financial responsibility), and a paper copy of the Notice of Medicare Non-Coverage (NOMNC - notice issued to beneficiaries before the end of Medicare covered Part A skilled services) for two Residents (#33 and #78) of three applicable residents reviewed for beneficiary notices, out of a total sample of 20 residents. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing program of group activities designed to meet the interests of and support the physical, mental, and psychological well-being of residents on two Units (3 and 4) out of three units.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of five percent or greater when one of two nurses observed, made two errors out of 34 opportunities, for a medication error rate total of 5.88%, affecting one Resident (#30) out of three residents observed. Specifically, for Resident #30, the facility failed to: -ensure that a blood pressure reading was obtained per Physician order, prior to administering Amlodipine (medication to treat high blood pressure) medication, putting the Resident at risk for hypotension (extremely low blood pressure) and related complications.-ensure that MiraLAX (medication to treat constipation) medication was administered as ordered, when the medication was not given, by signed off as given by staff, putting the Resident at risk for constipation.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interviews, the facility failed to adhere to infection control standards of practice, for one Resident (#14) out of a total sample of 20 residents, and on one Unit (Fourth Floor) out of three units observed. Specifically, the facility failed to:1. ensure that Resident #14's foley catheter drainage bag remained off the floor to prevent contamination putting the Resident at risk for catheter associated infections.2. ensure that ice in an ice chest was distributed to the residents on the Fourth Floor Unit under sanitary conditions.3. ensure the housekeeping staff adhered to appropriate infection control practices when cleaning consecutive rooms which included a room with contact precautions on the Fourth Floor Unit.
January 21, 2025Standard inspection · 13 citations
- 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 interview, and record review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care planning process for four Residents (#40, #89, #57 and #22) out of a total sample of 19 residents. Specifically, for Resident #40, #89, #57 and #22, the facility failed to ensure that: -quarterly care plan meetings were conducted as required -the Resident/Resident Representative were invited to participate in the care planning process. -the Interdisciplinary Team (IDT) met quarterly in 2024 to review the plan of care as required.
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation, and interview, the facility failed to post the required nurse staffing information daily as required. Specifically, the facility failed to: -post daily nurse staffing information in a prominent place, that was readily accessible to facility residents and visitors. -retain a copy of staffing records for 18 months as required.
- 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 interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent foodborne illness to residents. Specifically, the facility failed to: 1. Discard spoiled food and food that was past the use by date, and label and date prepared food. 2. Distribute and serve food in the main dining room under sanitary conditions.
- D
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, record review, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#7) out of a total sample size of 19 residents. Specifically, the facility failed to maintain the Resident's enteral feeding pump pole in a clean and sanitary manner when the base of the pole stand was visibly soiled with spilled substances.
- 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 interview, the facility failed to ensure prompt efforts to resolve a grievance for one Resident (#84) out of a total sample size of 19 residents. Specifically, for Resident #84, the facility failed to investigate and resolve a grievance for missing personal property when the Resident's electronic communication tablet that was used to communicate with staff was reported missing. Findings Include: Review of the facility policy titled, Administration: Grievance Policy, revised November 2016, indicated the following: -The facility will support the resident/responsible party to voice grievances/concerns regarding .lost articles or any violation of resident's rights. -Upon receipt of the grievance/concern the facility will take appropriate measures to seek a resolution to the concern. -The Administrator will appoint a Grievance Officer. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#79) out of a total sample of 19 residents. Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to dental status for Resident #79.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with personal hygiene care and services for two Residents (#15 and #57) out of a total sample of 19 residents. Specifically, the facility failed to ensure that: 1. Resident #15 was offered and/or provided with grooming assistance for fingernail care and facial hair care when the Resident was dependent on staff for both grooming tasks. 2. Resident #57 was offered and/or provided grooming assistance for fingernail care when the Resident was dependent on staff for this task.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#252) out of a total sample of 19 residents, who required renal dialysis. Specifically, the facility failed to ensure that an emergency kit including clamps and pressure dressings were kept with the Resident (#252) and the Resident's bedside as ordered, in the event of a medical emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).
- 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) was acted upon as required for one Resident (#20), of five applicable residents reviewed for unnecessary medications, out of a total sample of 19 residents. Specifically, the facility failed to act upon the Consultant Pharmacist recommendation dated 3/18/24, to update the Physician's order for Budesonide (inhaled steroid medication) to instruct the Resident to rinse mouth after use to prevent the development of oral thrush, after it had been approved by the Resident's Physician.
- 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, record review, and interview, the facility failed to ensure that drugs were stored in accordance with accepted professional standards of practice for a medication pass process for Resident #20 out of four medication passes observed. Specifically, the facility nursing staff failed to ensure that medications prepared for Resident #20 were secure and inaccessible to unauthorized staff and residents when Nurse #1 left the prepared medications on the top of the cart, left the cart unattended and unlocked in the hallway outside the Resident's room on multiple occasions, while administering the medications to the Resident in his/her room.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dental services were provided for one Resident (#79) out of a total sample of 19 residents. Specifically, the facility failed to provide dental services for Resident #79 after the Resident's Guardian requested dental services.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#12) who had tested positive for COVID-19, out of a total sample of 19 residents. Specifically for Resident #12, the facility failed to ensure that staff: -wore the necessary Personal Protective Equipment (PPE: items such as a gown, gloves, mask, eye protection, etc. to prevent transmission of communicable disease) to maintain isolation contact/droplet precautions (used to prevent transmission of a disease spread by touching a contaminated surface or person). -performed hand hygiene procedure after removing gloves as required.
- B
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation) for two Residents (#57 and #58), out of a total sample of 19 residents. Specifically, the facility failed to: 1. for Resident #57, accurately complete a Level I PASRR when the Resident's admission PASRR indicated no SMI, and the Resident was admitted to the facility with SMI diagnoses and a recent hospitalization where psychiatric services were provided resulting in a Level II PASRR Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services) not being completed as required. 2. [...]
November 21, 2023Standard inspection · 12 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, interviews and policy reviews, the facility failed to ensure that staff maintained a clean and sanitary facility kitchen. Specifically, the facility staff failed to ensure that: 1) food for resident consumption was stored appropriately to prevent contamination and were labeled and dated. 2) glove use and handwashing were performed to prevent potential contamination of food items. 3) hair restraints were worn to prevent potential physical contamination of food. 4) dishware used for resident meals/functions were clean and free of residue and debris. 5) an issue with the facility dish machine was identified when the minimum temperatures and sanitation requirements were not obtained as required. 6) the three compartment sink was utilized as required to appropriately clean/disinfect dishware/equipment used in resident meal service.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, record and policy review, the facility failed to ensure provide dignity with resident communal dining on one unit (Fourth Floor Unit), out of a total of three units observed. The facility also failed to ensure that one Resident (#40) out of a total sample of 20 residents, was provided dignity and privacy relative to medical care. Specifically, the facility staff failed to: 1) provide residents on the Fourth Floor Unit dignity during dining when disposable cups were provided during meals, the meals in the communal dining room were served on resident meal trays, and residents who were seated at the same table were not provided their meals at the same time. 2) ensure Resident #40 was afforded dignity and privacy when medical instructions were posted above his/her bed and could be viewed by other residents and visitors from the hallway.
- 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, record and policy reviews, the facility failed to implement the plan of care and/or Physician orders for four Residents (#16, #70, #18 and #60), out of a total sample of 20 residents. Specifically, the facility staff failed to ensure: -the air mattress was set per the Physician's orders for Resident #16 and Resident #70. -interventions per the individualized Falls Care Plan were implemented for Resident #18 and Resident #60.
- 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 store medications in a safe, clean, sanitary and secure manner. Specifically, the facility staff failed to: -Secure a medication cart when the cart was left unattended. -Store Fluoxetine (a medication used to treat Depression) and Acidophilus (a medication used to promote digestive health) under refrigeration as directed. -Maintain three bottles of Amantadine (a medication used to treat viruses) solution in a clean and sanitary condition.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on policy review, record review, and interview, the facility failed to provide the Pneumococcal Vaccine after obtaining informed consent for three Residents (#73, #60 and #26), out of five applicable residents. Specifically, the facility failed to: 1) ensure that staff offered the Pneumococcal Vaccine within 30 days of admission to the facility for two Residents (#73 and #60). 2) assess for eligibility and offer the Pneumococcal Vaccination based on the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#26).
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews and policy review, the facility failed to maintain an effective pest control program. Specifically, the facility staff failed to alert the Director of Maintenance of the presence of fruit flies in the facility's main kitchen, so that appropriate action could be initiated.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition for two Residents (#50 and #26), out of a total sample of 20 residents. Specifically, the facility did not submit a Preadmission Screening and Resident Review (PASRR- an evaluation done to determine if a resident had an intellectual or developmental disability and/or serious mental illness and if a Resident was in need of additional specialized support services at the facility) when: 1) Resident #50 received a new mental health diagnosis indicating a change in status. 2) when a PASRR did not accurately reflect Resident #26's current mental health diagnosis that indicated a change from their prior PASRR assessment.
- 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 observations, interviews, record and policy review, the facility failed to revise one Resident's (#16) out of a total sample of 20 residents, plan of care relative to limited Range of Motion (ROM) and device use. Specifically, the facility staff failed to notify the Rehabilitation Department when Resident #16 was unable to utilize the splints as recommended by therapy and ordered by the Physician so that the plan of care could be revised.
- 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, policy review, record review and interview, the facility failed to provide indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care consistent with professional standards related to infection control for one Resident (#7) out of a total sample of 20 residents. Specifically, -for Resident #7, the facility failed to maintain/secure the urinary drainage bag away from contaminated surfaces.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a significant medication error did not occur for one Resident (#10) out of an applicable sample of seven residents, in a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #10 was not administered Furosemide (a diuretic medication that increases the excretion of water from the body), when there was no Physician order in place to administer Furosemide.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that staff adhered to infection control guidelines to prevent contamination and the spread of infection. Specifically, the facility staff failed to follow proper infection control practices to administer medications in a sanitary manner.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure accurate Minimum Data Set (MDS) Assessments for two Residents (#33 and #70), out of a total sample of 20 residents. Specifically, the facility failed to: 1. ensure that Hospice services was accurately coded for Resident #33. 2. ensure incontinence was accurately coded for Resident #70.
Fire safety inspections
14 fire safety citations on file: 5 on April 14, 2026, 7 on January 21, 2025, 2 on November 21, 2023.
Every fire safety citation14 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · April 14, 2026 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · January 21, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 21, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · January 21, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 21, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 21, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 21, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 21, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 21, 2023 · Corrected (the home has a date of correction)