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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
20D
7E
0F
Potential for minimal harm
0A
2B
0C
March 19, 2025Standard inspection · 19 citations
- L
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, review of facility documentation, and interviews, the facility failed to follow the manufacturers' recommendations for replacing the Nephros water filters which were in place since [DATE], following a presumptive positive case of Legionella in a resident at the facility, and the facility failed to ensure that a positive Legionella water sample was reported to the State Agency in a timely manner. These failures resulted in the finding of Immediate Jeopardy.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #33 and Resident #336) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice and the facility failed to ensure that medication was not left at the resident's bedside for a resident who is without an order or assessment for self-administration.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure the second-floor windows contained mechanisms to prevent them from fully opening, presenting a safety hazard to residents residing on the unit (dementia unit).
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on review of facility documentation, facility policy, and interviews, the facility failed to complete license nurses and nurse aides education and competencies related to intravenous therapy (IV) therapy and the facility failed to ensure licensed nurses had intravenous therapy (IV) certificate.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, review of facility documentation, review of facility policy, and interviews for four of four medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy, and interviews for 5 of 5 sampled residents (Resident #14, 16, 24, 56, and 73) reviewed for immunizations, the facility failed to offer and provide influenza vaccine as required and for 4 of 5 residents (Resident #12, 26, 37, and 61) reviewed for immunizations, the facility failed to offer and provide pneumococcal vaccine as required.
- 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 clinical record reviews, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #2, 12, 19, 59, and 61) reviewed for immunizations, the facility failed to offer and provide Covid-19 immunizations as required.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wrotedocumentation, review of facility policy/procedures and interviews for two of two sampled residents (Residents #9 and #336) reviewed for choices, the facility failed to ensure the resident's choices were accommodated when the resident requested to go to bed, and staff did not assist the resident for four hours and failed to ensure menu choices were provided at mealtime.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews for one of two sampled residents (Resident #335) reviewed for advanced directives, the facility failed to ensure consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status from the resident/responsible party.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on review of clinical records, review of facility documentation, review of facility policy/procedure and interviews for one of two sampled residents (Resident #62) reviewed for Pre-admission Screening and Record Review (PASRR), the facility failed to ensure that a Level 2 determination was completed when the 30-day approval stay expired.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, review of clinical records, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #62) reviewed for unnecessary medication the facility failed to ensure that physician's orders were implemented and completed as prescribed by the physician and one of seven residents (Resident #335) reviewed for accidents the facility failed to ensure that medications were administered as prescribed by the physician.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of the clinical record, review of facility policy, and interviews for two of four sampled residents (Resident #36 and #286) reviewed for pressure ulcer/injury, the facility failed to ensure weekly skin audits were completed per the physician's order.
- 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 clinical record review, observations, review of facility policy/procedures and interviews for one sampled resident (Resident #24) reviewed for pressure ulcer/injury, the facility failed to ensure the bilateral hand rolls/rolled wash cloths were in place as ordered.
- 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 observations, clinical record reviews, facility policy review, and interviews for one sampled residents (Resident #51) for enteral feeding, the facility failed to ensure enteral feeding were properly labeled with date and time and discarded when appropriate in accordance to the facility policy.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #68) reviewed for pain management, the facility failed to ensure pain medication was administered in accordance with the physician's order.
- 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 review of the clinical record, review of facility policy, and interviews for one of five sampled residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure target behavior monitoring was completed, per the physician's order.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of the clinical records, review of facility policy, and interviews for two of three sampled residents (Resident #15 and #68) reviewed for pain management, the facility failed to ensure accurate administration documentation of pain medication.
- 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 review of facility documentation, review of facility policy and interviews, the facility failed to ensure the Office of the Sate Long-Term Care Ombudsman was notified of resident transfers and discharges on a monthly basis.
- 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 review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of four sampled residents (Resident #66) reviewed for hospitalization and had multiple hospitalizations, the facility failed to ensure the resident and/or resident representative were provided with written information regarding the bed hold policy.
December 19, 2024Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound care, the facility failed to ensure wound treatment recommendations were implemented.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound treatments, the facility failed to ensure the clinical record was complete and accurate to reflect wound treatments were administered.
November 15, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, (Resident #2), the facility failed to ensure a resident who is completely dependent on staff for transfers, wheelchair mobility, bed mobility and Activities of Daily Living (ADLs) remained free from significant injuries of unknown origin including bilateral (both sides) femur (bone in upper thigh) fractures.
July 14, 2022Standard inspection · 6 citations
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #19) reviewed for transfers, the facility failed have a system in place to assess residents per manufacturer guidelines for the use of the correct size hoyer pads for residents being transferred utilizing a mechanical lift.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #21, Resident #34 and Resident #70) reviewed for resident to resident altercations, the facility failed to protect a resident (Resident #28) from abuse and failed to protect Resident #21 and Resident #70 from resident to resident altercations.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, review of the clinical record, facility documentation and interviews for one of three residents (Resident #25) reviewed for pressure ulcers, the facility failed to ensure the specialty air mattress was maintained on the appropriate setting according to the residents weight and as per the physicians orders.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to ensure the accuracy of an admission dietary assessment to calculate fluid needs and obtain an admission weight timely.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to ensure laboratory blood work was completed timely as directed by the physician.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to notify the physician/Advanced Practice Registered Nurse (APRN) of abnormal lab values in a timely manner. Resident #85 was admitted to the facility from the hospital on 6/28/22 with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease, and recovering pneumonia secondary to Covid. The Hospital Intra-Agency Referral Report dated 6/28/22 noted Resident #85's lab values dated 6/28/22 identified a Sodium (NA) of 138 (135-146 is the normal range), Albumin 3.0 (3.6-5.1 is the normal range), and white blood cell count 11.4 (3.8-10.8 is the normal range). [...]
November 27, 2019Standard inspection · 3 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on clinical record review and staff interview for the only resident in the survey sample reviewed for Pre-admission Screening and Resident Review( PASARR) (Resident # 62), the facility failed to ensure a resident with a Level I pre-screen which later identified with a mental disorder was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation for the only resident in the survey sample reviewed for choices (Resident #51), the facility failed to ensure specialized test were conducted in accordance to the physician's orders.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures for one of three residents in the survey sample reviewed for pressure ulcers (Resident # 307), the facility failed to ensure interventions were implemented to ensure offloading and positioning/repositioning were performed to prevent the development of a pressure ulcer.
Fire safety inspections
11 fire safety citations on file: 5 on March 19, 2025, 5 on July 14, 2022, 1 on November 27, 2019.
Every fire safety citation11 citations
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 19, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 19, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 19, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 19, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 19, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 14, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 14, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 14, 2022 · Corrected (the home has a date of correction)
- F
Meet requirements for the use of electrical equipment.
K 919 · July 14, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 14, 2022 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · November 27, 2019 · Corrected (the home has a date of correction)