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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
2E
0F
Potential for minimal harm
0A
0B
0C
February 13, 2026Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interview, the facility failed to adhere to infection control and prevention standards related to multi-resident medical equipment use for one Unit (Sub Acute) out of two units observed, to mitigate the development and transmission of communicable diseases and infections. Specifically, the facility failed to:1. ensure that facility staff cleaned and disinfected a blood glucose monitor (BGM - device used to measure the amount of glucose [sugar] in the blood) between multi-resident use after Nurse #2 used the BGM to obtain finger stick blood sugar (FSBS) levels on two residents and before storing the BGM device in the medication cart with clean equipment.2. [...]
June 12, 2025Complaint inspection · 2 citations
- J
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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing) with several episodes of choking which required nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), the Facility failed to ensure his/her Dysphagia Care Plan was reviewed and/or revised related to effectiveness of interventions, when he/she remained on the same diet but continued to experience choking episodes and despite recommendations from Speech Therapy to implement a new intervention for direct supervision by staff during all meals, he/she was only supervised from a distance by staff. On 5/02/25, Resident #1 choked on his/her meal and died.
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing), was identified to be at increased risk for aspiration, with multiple choking episodes which required the nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), and for whom Speech Therapy had recommended the need for direct supervision by nursing staff while eating, the Facility failed to ensure they provided an adequate level of staff supervision for Resident #1 in an effort to maintain a safe environment, when on 5/02/25, he/she choked again on his/her meal, and although nursing staff performed the Heimlich Maneuver, Resident #1 died.
October 30, 2024Standard inspection · 10 citations
- 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 record review, policy review, and interview, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#94) out of a total sample of 23 residents. Specifically, for Resident #94, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #94's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#98), was free from physical restraints, out of a total sample of 23 residents. Specifically, for Resident #98, the facility failed to: -appropriately assess and re-assess the use and need of wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) as a restraint that was being used in the place of an ordered scoop mattress (a mattress with raised edges on all four sides to prevent accidental rolling out of bed). -obtain informed consent and review the risk/benefits with the Resident's Representative for the use of wedge cushions while the Resident was in bed to prevent him/her from exiting the bed, increasing the potential risk of accidental falls and injury.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after the completion date for 17 Residents (#4, #43, #57, #90, #95, #102, #103, #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118) out of a total sample of 23 residents. Specifically, the facility failed to ensure that: 1) Comprehensive MDS assessments for Resident's #4, #43, #57, #90, #95, #102, #103 were not submitted late with submission dates more than 14 days after the completion date. 2) Non comprehensive MDS assessments for Residents #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118 were not submitted late with submission dates more than 14 days after the completion date.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for one Resident (#85), out of a total sample of 23 residents.
- 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 for a Resident Review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#98), out of a total sample of 23 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness [SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #98 received emergency mental health interventions and was transferred to the hospital for a psychiatric evaluation.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to provide treatments in accordance with professional standards of practice for one Resident (#78) out of a total sample of 23 residents. Specifically, the facility failed to implement and perform care and treatment consistent with the Physician orders and professional standards of practice for a Resident with Diabetes Type II (DM II- a chronic medical condition where the body cannot effectively use insulin [hormone that regulates blood glucose/sugar] or produce enough insulin and has trouble controlling blood sugar levels), placing the Resident at risk for side effects of hyperglycemia (high blood sugar).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#87 and #24), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #87, routinely maintain the oxygen concentrator (a device used to deliver supplemental oxygen) air intake gross particle filter in accordance with Physician orders and manufacturers guidelines, placing Resident #87 at risk for equipment malfunction, impaired oxygen delivery and contamination. 2. For Resident #24, ensure that the Resident had an active Physician's order for nebulizer (delivery device used to administer medication in the form of an aerosol that is inhaled into the lungs) equipment care, handling, and storage, to prevent contamination and the spread of infections.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that professional standards of practice relative to dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) care and services for one Resident (#32), of two applicable residents reviewed for dialysis, out of a total sample of 23 Residents. Specifically, for Resident #32, the facility failed to: 1. Monitor and assess the Physician's ordered fluid restriction to ensure adequate fluid intake. 2. Provide food items prior to dialysis as indicated in the plan of care and per the Resident's preferences.
- 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, interview, and policy review, the facility failed to ensure that one Resident (#84), out of a total sample of 23 residents, was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility failed to ensure that appropriate monitoring for adverse consequences and side effects of antipsychotic medications using the Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale used to measure involuntary movements of the face, mouth, trunk, or limbs known as Tardive Dyskinesia (TD) in a resident taking antipsychotic medications) was completed timely in accordance with standards of practice.
- 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 contamination and stop the spread of infections for one Resident (#54), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #54, perform appropriate hand washing/hygiene for five opportunities, during a wound care procedure which increased the Resident's risk for wound contamination and infection. 2. For Resident #54, Adhere to Enhanced Barrier Precautions (EBP: infection control guidelines that use Personal Protective Equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]) during medication and fluid administration through a gastrostomy tube (G-tube: [...]
August 28, 2023Standard inspection · 14 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 and interview, the facility failed to maintain professional standards relative to food storage and sanitation in one of three nourishment kitchens.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, policy reviews and interviews, the facility failed to adhere to Infection Control policies/practices during a COVID-19 outbreak. Specifically the facility staff failed to: 1) utilize the appropriate precaution signs on one out of three units during an outbreak of COVID-19 infection. 2) use appropriate personal protective equipment (PPE) by staff in a manner that would minimize the spread of COVID-19 infection during an active outbreak for one Resident (#96) out of four applicable residents, out of a sample of 21 residents. 3) to ensure staff were tested for COVID-19 as required when the facility was experiencing an outbreak of COVID-19 infections.
- 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 informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for two Residents (#8, and #102), out of a total sample of 21 Residents. Specifically: 1. For Resident #8, the facility staff failed to ensure the correct medication dose was documented on the Informed Consent for the use of an antidepressant (medicine used to treat clinical depression) medication. 2. For Resident #108, the facility staff failed to ensure the Resident was: a) was given the right to be informed of the risk and benefits of the use of an antipsychotic (medication which are to treat psychosis) medication. [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review and interview, the facility failed to assess one Resident (#70), out of a total sample of 21 residents, for self-administration of medications. Specifically, the facility staff failed to determine if self-administration of medications was clinically appropriate for Resident #70 while at the Dialysis Clinic.
- 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 ensure a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) was submitted for one Resident (#48) out of a total sample of 21 residents. Specifically, for Resident #48, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: [...]
- 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 record review and interview, the facility failed to implement a comprehensive person-centered care plan for one Resident (#35), out of a total sample of 21 Residents. Specifically, for Patient #35, the facility staff failed to implement a care plan with interventions related to a re-occurring health problem that resulted in required hospitalizations.
- 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 and interview, the facility failed to include one Resident (#21) and/or their Resident Representative in the care planning process out of a total sample of 21 residents. Specifically, the facility staff was unable to provide evidence that Resident #21, and/or their Resident Representative had been invited to, and/or were included in care plan meetings as required.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide care and treatment consistent with professional standards of practice to prevent the development and worsening of a pressure injury for one Resident (#96), out of a total sample of 21 residents. Specifically, the facility staff failed to: 1) Follow a Physician order for air mattress setting as an intervention to prevent pressure injury. 2) Follow a Physician ordered treatment to a pressure ulcer on the Resident's sacral region (the portion of the spine between the lower back and tailbone), lower medial coccyx (base of the spine, also known as the tail bone).
- 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, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) for one Resident (#96) out of five applicable residents who required an indwelling urinary catheter, out of a total sample of 21 Residents. Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #96 as ordered.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dialysis (a process by which waste substances are removed from a patient's body) care and services were provided for one Resident (#70), out of five applicable resident who received dialysis out of a total sample of 21 residents. Specifically, the facility failed to ensure that its staff maintained ongoing communication and documentation with the dialysis center, including medication management, and assessment of the residents' condition before and after dialysis treatment, including site care, vital signs and weights.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview, policy and record review, the facility failed to ensure one Resident (#96) was free of significant medication errors, out of a total sample of 21 residents. Specifically, the facility failed to ensure that its staff followed Physician's orders for: 1. Scheduled morphine (medication is used to treat severe pain) prior to a pressure ulcer dressing change as ordered. 2. By administering Morphine more frequently than ordered.
- D
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Inspectors wroteBased on record review and interview, the facility failed to obtain Physician ordered laboratory specimens for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility staff failed to obtain a Hemoglobin A1C (Hgb A1C - a blood test that measures the average blood sugar level over the past three months) level for Resident #11 as ordered by the Physician.
- D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Food Service Director (FSD) held the required qualifications. Specifically, the facility failed to ensure there was a full-time Registered Dietitian (RD) when the FSD: -was not a certified dietary manager. -was not a certified food service manager. -did not have a similar national certification in food service management and safety. -did not have an Associate's degree or higher in food service management or in hospitality. -did not have two or more years of experience in the position of Director of food and nutrition services in a nursing facility setting.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on document review and interview, the facility failed to offer and administer a Pneumococcal Immunization when requested, for one Resident (#8), out of total sample of 21 Residents.
Fire safety inspections
9 fire safety citations on file: 1 on February 13, 2026, 7 on October 30, 2024, 1 on August 28, 2023.
Every fire safety citation9 citations
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 13, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · October 30, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 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 · October 30, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · October 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 · October 30, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 30, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 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 28, 2023 · Corrected (the home has a date of correction)