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 51 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
36D
12E
2F
Potential for minimal harm
0A
0B
0C
March 12, 2026Complaint inspection · 2 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteThe facility staff failed to implement the facility abuse policies for one Resident (Resident #1) of 2 residents in the survey sample.
- D
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 staff interview, Resident interview, clinical record review, and facility documentation review, the facility staff failed to maintain competency necessary to care for resident needs in Nursing Aide proficiency related to leaves of absence (LOA) for one Resident (Resident #1) of 2 Residents in the survey sample.
January 14, 2026Complaint inspection · 5 citations
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #108, #107, and #124) in the survey sample had meals served that followed the menu and meal tickets.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on resident interview, staff interview, and clinical record review the facility staff failed to provide needed durable medical equipment and home health services in a timely manner for 1 of 27 residents (Resident #115), in the survey sample.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 4 of 28 residents (Residents #124, #122, #108, and #107) in the survey sample received fluids as listed on the menu, per their preferences, or as ordered.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an enhanced barrier precaution sign was posted for 1 resident to prevent the spread of infection for 1 of 28 residents (Resident # 117), in the survey sample.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to maintain a sanitary and comfortable environment for all.
September 24, 2025Complaint inspection · 6 citations
- J
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on staff interviews, Facility documentation reviews, and clinical record reviews, the facility staff failed to ensure competent Professional nursing staff oversight, assessment, and administration of tracheostomy care for three residents (Resident #185, #186, and #190) in a survey sample of 60 Residents, resulting in Immediate Jeopardy. After accepting the plan to remove the immediacy from the Administrator and confirming that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of 3 (G), isolated (harm).
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #108, #107, and #124) in the survey sample received fluids as listed on the menu, per their preferences, or as ordered.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on resident interview, staff interview, and clinical record review the facility staff failed to provide needed durable medical equipment and home health services in a timely manner for 1 of 28 residents (Resident #115), in the survey sample.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #124, #108, and #107) in the survey sample had meals served in accordance with the menu and meal tickets.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an enhanced barrier precaution sign was posted for 1 resident to prevent the spread of infection for 1 of 28 residents (Resident # 117), in the survey sample.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to maintain a sanitary and comfortable environment for all.
September 5, 2024Complaint inspection · 1 citation
- 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, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide timely incontinence care after each episode for 1 of 5 residents (Resident #1), in the survey sample.
July 15, 2021Standard inspection · 12 citations
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on general observations of the facility, staff and resident interviews, the facility staff failed to maintain an effective pest control program. Roaches were identified during the survey and recorded sightings by staff on all four floors (three resident units and first floor kitchen and common areas).
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure that 3 of 56 residents (Resident #71, Resident #141 and Resident #129) in the survey sample received a complete and accurate assessment.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, clinical record review, staff and resident interviews, the facility staff failed to ensure 8 of 56 (Residents #119, #239, #114, #106, #129, #126, #60 #22) residents grooming and personal hygiene needs were met.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure for 1 of 56 residents in the survey sample, Resident #442 received Gabapentin medication as ordered.
- D
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on information obtained during the Resident Council Meeting, and interviews, the facility staff failed to inform residents of where State licensing Agency contact information was posted to include email, addresses and phone numbers.
- 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 staff interview, facility documentation review and clinical record review the facility staff failed to ensure for 1 of 56 residents in the survey sample, Resident #121, was provided an opportunity to formulate an advanced directive.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record review and staff interviews the facility staff failed to provide one resident (Resident #189) in the survey sample of 56 residents with documentation of a comprehensive care plan goals during discharge/transfer to a hospital.
- D
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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 56 residents (Resident #60 and Resident #189) in the survey sample.
- D
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 staff interviews the facility staff failed to provide one resident (Resident #189) in the survey sample of 56 residents with a notice of Bed Hold Policy before being transferred to the hospital.
- 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 resident interview, staff interview, and clinical record review the facility's staff failed to develop a person-centered comprehensive care plan to include use of an indwelling catheter for 1 of 56 residents (Resident #126), in the survey sample.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interview, and clinical record review the facility's staff failed to obtain a physician's order for use of an indwelling catheter for 1 of 56 residents (Resident #126), in the survey sample.
- 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, resident interview, staff interview, and clinical record review the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce complications while utilizing an indwelling catheter for 1 of 56 residents (Resident #114), in the survey sample.
May 9, 2019Standard inspection · 16 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The facility staff failed to staff a RN for at least 8 consecutive hours a day on 10/7/17, 10/21/17 and 10/22/17. This affects all residents.
- E
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their care plan goals after being discharged /transferred to the hospital for 3 of 60 residents (Resident #52, 51 and 3) in the survey sample. 1. The facility staff failed to send Resident #52's Care Plan Summary to include goals when discharged to the hospital on [DATE]. 2a. The facility staff failed to convey to the receiving provider Resident #51's comprehensive care plan goals at the time of discharge to the local hospital on [DATE]. 2b. The facility staff failed to convey to the receiving provider Resident #51's comprehensive care plan goals at the time of discharge to the local hospital on 2/7/19. 3. Facility staff failed to evidence that all the required documentation; [...]
- E
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 staff interviews, clinical record review and facility documentation review the facility staff failed send a copy of the Bed-Hold Policy for 5 of 60 residents (Resident #52, 79, 51, 55 and 3) after being transferred to and admitted to the hospital. 1. The facility staff failed to ensure that Resident #52 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE]. 2. The facility failed to provide Resident #79 with a written notice of the facility's Bed-Hold Policy upon transfer to the hospital 4/17/19. 3. The facility staff failed to ensure Resident #51 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on [DATE] and 2/7/19. 4. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to dispose of controlled medications in a secure and safe method to prevent diversion and/or accidental exposure upon inspection of 1 out of 3 medication carts.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on information obtained during the Resident Council Meeting, observations and interviews, the facility staff failed to respond to ongoing resident issues.
- D
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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 1 of 60 residents (Resident #52) in the survey sample. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #52's transfer to the hospital on [DATE].
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interviews, and review of the facility's policy the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 60 residents (Resident #92), in the survey sample. The facility staff failed to code hearing and vision loss in section B0200 and B1000 and hospice services in section O0100K2 of Resident #92's 4/1/19 quarterly MDS assessment.
- 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 clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the baseline care plan summary was provided for 1 out of 60 residents (Resident #453) in the survey sample. The facility staff failed to issue a newly admitted resident, (Resident #453), a copy of the care plan summary. The summary must include the initial goals for the resident, a list of current medications and dietary instructions and services and treatments to be administered by the facility.
- 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, resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to implement the comprehensive care plan for one of 60 residents in the survey sample, Resident #31. Facility staff failed to implement the comprehensive care plan and ensure Resident #31's environment was free from fall hazards.
- 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 resident interview, staff interview, clinical record review and review of the facility's policy the facility staff failed to assure the person centered plan of care was revised as the resident's status changed for 1 of 60 residents, (Resident #79) in the survey sample. The facility staff failed to revise Resident #79's care plan after a fall to reduce the likelihood of another fall.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record review, staff interviews, and review of the facility's policy the facility staff failed to provide care and services to maintain the resident's highest physical well-being for 1 of 60 residents (Resident #92), in the survey sample. The facility staff failed to follow the physician's order dated 6/29/18 and the person centered-care plan for, no weights for Resident #92.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wrote2. The facility staff failed to provide fingernail care for Resident #74, prior to his fingernails becoming long and with broken sharp edges. Resident #74 was originally admitted to the facility 11/24/17 and has never been discharged from the facility. The current diagnoses included; stroke, difficulty speaking, and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/22/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of 15. This indicated Resident #74's daily decision making abilities were severely impaired. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on information gleamed during a complaint investigation, resident interviews, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to provide an environment which is free from accident hazards and elopement by implementing interventions and supervision for 3 of 60 resident in the survey sample, (Resident #79, 553 and 31). 1. The facility staff failed to identify Resident #79's inability to hold her leg/foot up for prolonged periods while being propelled in a wheel chair; which resulted in an avoidable fall. 2. The facility staff failed to provide necessary supervision to Resident #553 to prevent elopement from the facility. 3. The facility staff failed to ensure Resident #31's bathroom was free from fall hazards.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 60 residents (Resident #453) in the survey sample with Respiratory care in accordance with professional standards of practice. The facility staff failed to ensure Resident #453's oxygen order contained a prescribed flow rate to be administered.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on clinical record review, staff interviews, and review of the Hospice policy; the facility staff failed to integrate the Hospice Agency's written agreement describing the responsibilities between the hospice agency and the nursing home for 1 of 60 residents (Resident #92), in the survey sample. The facility staff failed to ensure the Hospice Agency's coordinated plan of care for Resident #92, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency was integrated with the facility's care plan.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, medical record review, facility documentation review, and staff interview the facility staff failed to ensure infection control measures were provided during wound care and the facility staff failed to conduct a risk assessment to reduce the risk of Legionella on 1 residents. (Resident #55) of 60 residents in the survey sample. For Resident #55, the facility staff failed to place a barrier under the Resident's Right Lower Extremity (right heel) while providing wound care and to sanitize equipment used in wound care (scissors and bedside table).
August 17, 2017Standard inspection · 9 citations
- E
Provide necessary care and services to maintain or improve the highest well being of each resident .
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to provide the necessary care and services to promote and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 25 residents in the survey sample (Residents #2 and #6). 1. The facility failed to obtain a Physician Order to cleanse a traumatic wound with Normal Saline and to apply a clean dressing for Resident #2. 2. The facility staff failed to identify two staples remaining in Resident #6's healed surgical sacral suture line.
- E
Ensure that residents are safe from serious medication errors.
Inspectors wroteBased on observation, clinical record review, staff interview and facility documentation the facility staff failed to administer two (2) significant medications for 1 out of 25 residents in the survey sample, (Resident #20). The facility staff failed to transcribe and administer 3 doses of Clonidine (1) and 7 doses of Methyldopa (2) (Hypertensive medications) as ordered by the cardiologist.
- E
Store, cook, and serve food in a safe and clean way.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain the proper food temperature at one of 3 nursing units. The facility staff failed to maintain the proper temperature for hot foods at 135 degrees Fahrenheit (F) or above at one of the nursing units, Unit 2.
- E
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on resident interview, staff interviews, and clinical record review, the facility staff failed to assist 1 of 25 residents (Resident #6), in the survey sample to arrange dental services. The facility staff failed to assist Resident #6 to have his broken lower denture repaired or replaced.
- D
Try to resolve each resident's complaints quickly.
Inspectors wroteBased on resident interview, staff interviews, and clinical record review, the facility staff failed to promptly resolve a grievance for 1 of 25 residents (Resident #6), in the survey sample. The facility staff failed to resolve Resident #6's grievance to have his broken lower denture repaired or replaced.
- D
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Inspectors wroteBased on observations, resident interview, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to provide care and services to identify new pressure injuries for 1 of 25 residents (Resident #6), in the survey sample. The facility staff failed to identify a new pressure ulcer to the base of Resident #6's neck and a change in the right lateral foot deep tissue injury to a stage 2 pressure injury.
- D
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Inspectors wroteBased on observation, staff interview, facility documentation review, clinical record review the facility staff failed to discard medication prior to the expiration date in 1 of three Medication Storage Rooms (Unit 2).
- D
Have a program that investigates, controls and keeps infection from spreading.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility failed to ensure infection control practices were maintained to prevent the potential development and transmission of infection during wound care for three of 25 Residents in the survey sample, Resident #1, #2, and #14. 1. For Resident #1 staff failed to ensure proper handwashing and provide a clean barrier field for supplies during wound care. 2. For Resident #2 staff failed to ensure proper handwashing and provide a clean barrier field for supplies during wound care. 3. For Resident #14 staff failed to ensure proper handwashing, maintain clean barrier field and prevent contamination of supplies during wound care.
- D
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to maintain an accurate medical record for 1 of 25 residents in the survey sample, Resident #14. The facility staff failed to accurately document a physician order of Cranberry capsule for Resident #14. It was ordered to be administered per gastronomy tube (G Tube) (1) but it was transcribed by the nurse to be administered by mouth.
Fire safety inspections
23 fire safety citations on file: 7 on July 15, 2021, 14 on May 9, 2019, 2 on August 17, 2017.
Every fire safety citation23 citations
- D
Have simulated fire drills held at unexpected times.
K 712 · July 15, 2021 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 932 · July 15, 2021 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · July 15, 2021 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · July 15, 2021 · Corrected (the home has a date of correction)
- C
Develop Emergency Preparedness policies and procedures.
E 13 · July 15, 2021 · Corrected (the home has a date of correction)
- C
List the names and contact information of those in the facility.
E 30 · July 15, 2021 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · July 15, 2021 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · May 9, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 9, 2019 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 9, 2019 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 9, 2019 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 9, 2019 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 9, 2019 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · May 9, 2019 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · May 9, 2019 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · May 9, 2019 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · May 9, 2019 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · May 9, 2019 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · May 9, 2019 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · May 9, 2019 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · May 9, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 17, 2017 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · August 17, 2017 · Corrected (the home has a date of correction)