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 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
6E
3F
Potential for minimal harm
0A
0B
0C
June 11, 2025Complaint inspection · 2 citations
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure a resident with continued weight loss was provided with nutritional supplements as ordered. This affected one resident (#5) of three residents reviewed for weight loss. The facility census was 82.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, facility policy review and review of The Center for Clinical Standards and Quality QSO-24-08-NH memo, the facility failed to follow enhanced barrier precautions (EBP) during wound care. This affected one resident (#61) of one resident observed for wound care. The facility census was 82.
May 8, 2025Standard inspection · 8 citations
- 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, interview, and facility policy review, the facility failed to label and store food in a safe manner. This affected all the residents residing in the facility, except Resident #69 who was nothing by mouth. The facility census was 82.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure Resident #51 had appropriate diagnosis for psychotropic's and failed to monitor Resident #51's behaviors. This affected one residents (#51) of five residents reviewed for unnecessary medications. The facility census was 82.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and medical record review the facility failed to ensure the state was notified of a change in mental disease for Resident #28 and #51. This affected two residents (#28 and #51) of two residents reviewed for Preadmission Screening/Resident Review Identification Screen (PASARR). The facility census was 82.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to develop a comprehensive plan of care for two residents (#5 and #184) in the area of swallowing strategies and c-pap use. This affected two residents (#5 and #184) of 23 sampled residents. The facility was 82. Findings Include: 1. Review of the medical record for Resident #5 revealed an initial admission date of 07/25/24 with the diagnoses including but not limited to cerebrovascular disease, fungal endocarditis, choledocholithiasis, Alzheimer's disease, hypothyroidism, obstructive and reflux uropathy, dysphagia, hyperlipidemia, seizures, chronic kidney disease, retention of urine, benign prostatic hyperplasia, abdominal aortic aneurysm, gastro-esophageal reflux disease and dementia. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and medical record review, the facility failed to provide daily wound care as ordered for Resident #182. This affected one (Resident #182) out of one resident reviewed for skin impairment. The facility census was 82.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wrote2. Review of the medical record for Resident #62 revealed an admission date of 03/19/25, with diagnoses including urinary tract infection, moderate protein-calorie malnutrition, abnormal weight loss, and type two diabetes mellitus. Review of weight record for Resident #62 revealed on 03/17/2025, the resident weighed 215.6 lbs. On 04/14/2025, the resident weighed 190.8 lbs, which reflects an 11.50% loss. Review of care plan dated 03/20/25 revealed the resident is at risk for altered nutrition related to urinary tract infection, candidal sepsis, impaired skin integrity, diabetes, edema, obesity, and the need for a therapeutic diet. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, review of medical record, and review of facility policy the facility failed to have physician orders in place for Resident #184's Bilevel Positive Airway Pressure (BiPAP) and failed to ensure oxygen orders were followed and oxygen administration was documented for Resident #33. This affected two residents (#33 and #184) of three residents reviewed for respiratory care. The facility census was 82. 1. Review of Resident #33's medical record revealed an admission date of 04/15/22 with diagnoses including chronic obstructive pulmonary disease, moderate protein- calorie malnutrition, unspecified dementia, generalized anxiety disorder, dysphagia, major depressive disorder, and altered mental status. Review of Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident was rarely or never understood. He received oxygen therapy. [...]
- 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 medical record review the facility failed to ensure the physician gave a clear reason why a pharmacy recommended gradual dose reduction (GDR) was not performed on residents with psychotropic's. This affected two residents (#28 and #51) of five residents reviewed for unnecessary medications. The facility census was 82.
November 19, 2024Complaint inspection · 3 citations
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, staff interview, and review of a repair bid from an outside vendor, the facility failed to maintain the dish machine in the kitchen in safe operating condition. This had the potential to affect all of the residents residing in the facility. The facility census was 74 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene during meal service. This affected four (Residents #34, #35, #36, #37) of 44 residents residing on the Pleasantville Unit. The facility census was 74 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, resident interview, and review of the facility policy, the facility failed to provide residents with a dignified dining experience by serving resident meals on Styrofoam tableware and cups with plastic cutlery. This affected three (Residents #30, #42, and #73) of three residents observed for meal service and had the potential to affect all of the residents residing in the facility. The facility census was 74 residents.
February 26, 2024Standard inspection · 6 citations
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of quality assurance and performance improvement (QAPI) meeting sign in sheets, staff interview, and facility policy review, the facility failed to ensure the infection preventionist attended the QAPI meetings. This had the potential to affect all 80 residents in the facility. The census was 80.
- F
Provide and implement an infection prevention and control program.
Inspectors wrote2. Review of the medical record for Resident #11 revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including vascular dementia, weakness, anxiety, heart disease and unspecified urinary incontinence. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/14/23, revealed Resident #11 had severely impaired cognition, required staff assistance for activities of daily living (ADL) tasks and was always incontinent of urine and bowel. Review of Resident #11's ADL care plan, dated 12/29/22, revealed Resident #11 required assistance from staff for incontinence care. Further review of the incontinence care plan, dated 09/02/21, revealed Resident #11 required staff to assist with changing clothing, incontinence briefs, and linens as needed due to soiling. Observation on 02/26/24 at 9:49 A.M. [...]
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to serve residents in a dignified manner during the dinner meal service. The deficient practice affected eight residents (Residents #6, #11, #18, #24, #32, #39, #50, and #54) of 14 residents who served meals in the dining room on the memory care unit (Speret Hall). The facility census was 80.
- E
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 resident interview, observation, staff interview, and facility policy review, the facility failed to maintain air temperature at a comfortable level in the small dining room. This had the potential to affect 54 (Residents #2, #3, #6, #8, #9, #10, #12, #13, #15, #16, #20, #22, #23, #27, #28, #29, #30, #31, #34, #37, #40, #41, #43, #44, #46, #47, #48, #49, #53, #56, #57, #58, #59, #62, #68, #69, #71, #72, #73, #74, #77, #134, #136, #137, #139, #140, #141, #142, #284, #285, #334, #335, #336, and #337) of 80 residents in the facility who could go to the small dining room. The census was 80.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on review of Monthly Infection Tracking Logs, staff interviews, and facility policy review, the facility failed to ensure the appropriate use of antibiotics according to their antibiotic stewardship program (ASP). This affected six (Residents #7, #40, #42, #51, #58, and #253) out of 80 residents in the facility. The facility census was 80.
- D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on medical record review, review of insurance records, review of financial records, and staff interview, the facility failed to provide spend down notices to residents and/or resident representatives when their personal funds account was within $200 of the Medicaid personal funds limit. This affected two (Residents #2 and #20) of five residents reviewed for personal funds accounts. The census was 80.
April 4, 2022Standard inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, facility policy and procedure review, review of guidance from the Centers for Disease Control (CDC) and interview the facility failed to maintain adequate and acceptable infection control practices during medication administration for Resident #13 and for Resident #232 who was in isolation to prevent the spread of infection including COVID-19. Observations during medication administration revealed medications were handled by the nurse with bare hands when administering to Resident #13 and two State Tested Nursing Assistants (STNAs), STNA #43 and STNA #58 were observed to enter Resident #232's room, a resident who was in droplet isolation precautions for COVID-19 without applying all required personal protective equipment (PPE) including gown and gloves. [...]
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on medical record review, financial record review, staff interview and facility policy and procedure review the facility failed to maintain accurate and timely accounting practices for services received and charged to Resident #3. This affected one resident (#3) of six residents whose financial records were reviewed. Findings Include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, sepsis, type II diabetes mellitus, chronic kidney disease, osteoarthritis, hypertension, major depressive disorder, anxiety disorder, psychosis, dementia, mood disorder, dysphagia and cognitive communication deficit. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22 revealed the resident was cognitively impaired. [...]
Fire safety inspections
9 fire safety citations on file: 1 on May 8, 2025, 4 on February 26, 2024, 4 on April 4, 2022.
Every fire safety citation9 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 26, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 26, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 26, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 26, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 4, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 4, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 4, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 4, 2022 · Corrected (the home has a date of correction)