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 34 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
28D
6E
0F
Potential for minimal harm
0A
0B
0C
August 28, 2025Standard inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for one Resident (#89), out of a total sample of 26 residents. Specifically, for Resident #89 the facility failed to provide assistance with the removal of facial hair.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview, the facility failed to follow up on a significant weight change in a timely manner and failed to implement a nutrition intervention as recommended by the Registered Dietitian (RD) for one Resident (#11), out of a total of 26 residents. Specifically, the facility failed to assess a significant weight loss for over 11 weeks and implement interventions for a nutrition supplement as recommended by the RD for Resident #11.
August 30, 2024Standard inspection · 13 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#10), out of 27 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility.
- 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 store, prepare and serve food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was properly labeled in two out of two refrigerators in the kitchen; and 2. Properly label, date, and store food products in two of two nourishment kitchenettes.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to ensure that residents and/or their representatives were fully informed in advance and given information necessary to make health care decisions including the dose and benefits of psychotropic medications prior to their use for one Resident (#32), from a total sample of 27 residents.
- 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 interview, the facility failed to ensure the Physician/Practitioner was notified of a change in treatment for one Resident (#17), out of a total sample of 27 residents. Specifically, the facility failed to ensure the Physician/Practitioner was notified when the Wound Consultant recommended the initiation of an antibiotic.
- 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 observations and interviews, the facility failed to maintain a clean, safe, comfortable, and homelike environment for the residents at the facility, for 1 of 3 nursing units.
- 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 record review and interview, the facility failed to ensure staff developed a baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care for two Residents (#96 and #251), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #96, to develop and implement a baseline care plan related to falls; and 2. For Resident #251, to ensure staff provided the resident and/or their representative with a summary of the baseline care plan within 48 hours of his/her admission.
- 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 observations, interviews, and records reviewed for two Residents (#35 and #52), out of 27 sampled residents, the facility failed to develop and/or implement comprehensive care plans to reflect the individual needs of the resident. Specifically, the facility failed: 1. For Resident #35, to develop and implement a comprehensive person-centered care plan to address the Resident's diagnoses of dementia with behavioral disturbance and psychotic disorder with delusions; and 2. For Resident #52, to develop and implement a comprehensive person-centered care plan to address trauma informed care related to post-traumatic stress disorder (PTSD) diagnosis.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#35 and #63), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #35, a. to ensure that the Resident's fingerstick blood sugar was obtained per physician's order, b. to ensure that a physician's order was in place for the care and maintenance of the Resident's catheter drainage bag, and c. to ensure that a voiding trial (a procedure in which the ability of the bladder to empty after removal of a urinary catheter is measured) on 8/23/24 was implemented per physician's order; and 2. For Resident #63, to ensure physician's orders were complete for the management of a continuous glucose monitoring sensor and included orders to remove and change the device every 14 days.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#57), out of a total sample of 27 residents. Specifically, the facility failed to fully develop and implement interdisciplinary care plans related to his/her dominant language of Albanian and failed to ensure staff provided person-centered care and services to determine and support the Resident's communication needs.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental and psychosocial well-being for one Resident (#251), out of 27 sampled residents. Specifically, for Resident #251, the facility failed to consistently provide activities based on the comprehensive assessment and care plan.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from accident hazards for two Residents (#32 and #62), out of a total sample of 27 residents. Specifically, the facility failed to complete his/her quarterly smoking evaluations.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review, policy review, and interview, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting; a blood thinner) for one Resident (#41), out of a total sample of 27 residents.
- 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 record review and interview, the facility failed to ensure one Resident's (#56) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 27 residents. Specifically, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days, or extended beyond 14 days with a documented clinical rationale and duration.
June 30, 2023Standard inspection · 19 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that concerns addressed by the Resident Council Group have sufficient follow-up to address and prevent recurrence.
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure four Residents (#75, #46, #31, and #21) were free from restraints, out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #75, to assess the use of a rolled-up Hoyer pad and pillows under the fitted sheet on both sides of the Resident as a potential restraint; 2. For Resident #46, to assess the use of multiple blankets under the sheets on both sides of the bed as a potential restraint; 3. For Resident #31, to assess the use of blankets under the fitted sheet on one side of the Resident as a potential restraint; and 4. For Resident #21, to assess the Resident's bed up against the wall as a potential restraint.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to four dependent Residents (#87, #40, #54, and #12), out of a total sample of 26 residents. Specifically, 1. Resident #87's facial hair was not removed timely; and 2. Residents #40, #54, and #12 were not supervised with eating.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, policy review, and interviews, the facility failed to store food in sanitary conditions, specifically, label and date leftover food items and dispose of food items after their use by date.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to provide a dignified existence for one Resident (#16), out of a total sample of 26 residents.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#16 and #54) consented to the administration of an antipsychotic medication, prior to administration, out of a total sample of 26 residents.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide meal choices and preferences for one Resident (#27), out of a total sample of 26 residents.
- 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 observations, records reviews, and interviews, the facility failed to implement the plan of care for three Residents (#451, #54 and #82), out of a total of 26 sampled residents. Specifically, the facility failed: 1. For Resident #451, to ensure nursing implemented a physician's ordered bed alarm for a resident with a history of a fall with injury; 2. For Resident #54, to implement the orthotic/splint care plan; and 3. For Resident #82, to develop a communication care plan.
- 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 record review, policy review, and interviews, the facility failed to revise the plan of care related to advanced directives for one Resident (#451), out of a total sample of 26 residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure professional standards of care were followed related to physician's orders for two Residents (#63 and #4) out of 26 sampled residents. Specifically, the facility failed: 1. For Resident #63, to obtain weekly weights, per the physician's order; and 2. For Resident #4, to ensure the physician's orders were implemented for a.) a stop sign outside of his/her room, and b.) the application of compression stockings (TEDs).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure quality care was provided to one Resident (#451), out of a total sample of 26 residents. Specifically, on 6/5/23 Resident #451 fell while in the facility and sustained a subdural hematoma and laceration to his/her right forehead and was transferred to the hospital. Resident #451 returned on 6/8/23 with four sutures to his/her right forehead. On 6/27/23, 6/28/23 and 6/29/23 (24 days after the sutures were inserted) the sutures were still in Resident #451's right forehead and nursing failed to obtain a suture removal date.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure that routine devices (hearing aids) used to maintain hearing were provided for one Resident (#451), out of 26 sampled residents. Specifically, the facility failed to provide and implement the use of hearing aids for Resident #451 who was hard of hearing.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow the Weight Surveillance policy for one Resident (#87), out of a total sample of 26 residents. Specifically, the facility did not obtain monthly weights as ordered for Resident #87 and did not reweigh Resident #87 when a 12.5% weight loss was recorded to ensure accuracy of the weight obtained.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews, policy review, and interviews, the facility failed to maintain respiratory equipment according to professional standards of practice for two Residents (#27 and #452), out of a total sample of 26 residents. Specifically, the facility failed: 1. To label the oxygen tubing and clean the filter as ordered; and 2. To implement a physician's order for dating and initialing nebulizer tubing, and to store a nebulizer face mask to prevent possible contamination.
- 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 record review, policy review, and interviews, the facility failed to ensure that pharmacy recommendations were reviewed and addressed for three Residents (#21, #12, and #86), out of a total sample of 26 residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of four nurses observed made 3 errors in 36 opportunities on two of three units resulting in a medication error rate of 8.33%. These errors impacted two Residents (#20 and #95), out of seven residents observed.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#4) was free from a significant medication error, out of a total sample of 26 residents. Specifically, Resident #4 was administered an antibiotic twice daily for 14 days instead of twice daily for 14 doses (7 days) as indicated by the hospital discharge summary and discharge prescription.
- 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 observations, policy review, and interviews, the facility failed: 1. To ensure medications were stored securely in 2 out of 4 resident care units, and 2. To ensure medications with shortened expiration dates were labeled and dated after being opened in 2 out of 3 medication carts.
- 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, policy review, and interview, the facility failed to ensure they maintained a complete and accurate medical record for one Resident (#4), out of a total sample of 26 residents. Specifically, for Resident #4, the physician's ordered calcium carbonate tablet did not have a dose as required.
Fire safety inspections
14 fire safety citations on file: 8 on August 28, 2025, 6 on August 30, 2024.
Every fire safety citation14 citations
- F
Conduct testing and exercise requirements.
E 39 · August 28, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 28, 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 · August 28, 2025 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 28, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 28, 2025 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 28, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 28, 2025 · Corrected (the home has a date of correction)
- C
Provide a written emergency evacuation plan.
K 711 · August 28, 2025 · no revisit needed
- F
Implement emergency and standby power systems.
E 41 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 30, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 30, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 30, 2024 · Corrected (the home has a date of correction)