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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
4E
0F
Potential for minimal harm
0A
1B
1C
July 14, 2026Complaint inspection · 2 citations
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of clinical records and interview with staff and resident, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for one of six residents reviewed for pain management (Resident R1). Findings Include: Review of Resident R1's clinical record revealed that R1 was admitted to the facility on [DATE], with diagnoses of generalized abdominal pain, pain unspecified, hemorrhoids (rectal veins), interstitial pulmonary disease (lung fibrosis), bilateral carpal tunnel syndrome (wrist neuropathy), abrasion of the left breast, initial encounter (breast scrape), pruritus (itching), rheumatoid arthritis (inflammatory arthritis), and cervical spinal stenosis (neck stenosis). [...]
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on review of facility policy, observation, clinical record review, review of facility documentation, and resident and staff interview it was determined that the facility failed to ensure that call bells were answered in a timely manner for two of six residents reviewed (Resident R1 and R6).
March 6, 2025Standard inspection · 9 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 observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the hand hygiene during medication administration, and wound treatment for two of two residents observed. (Resident R67 and Resident R57)
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of the proposed care, for one of six residents reviewed for psychotropic medications (Residents R396).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of five residents reviewed for medication safety (Resident R80).
- 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 the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for 3 of 4 residents reviewed for hospitalizations. (Resident R1, R59, and R246) Findings Include: Review of nursing note for Resident R1, dated August 24, 2024, revealed that the resident was discharged to the hospital for shortness of breath. Review of nursing note for Resident R59, dated October 27, 2024, revealed that the resident was discharged to the hospital for evaluation and treatment. Another nursing note for Resident R59, dated November 12, 2024, revealed that the resident was discharged to the hospital for shortness of breath. [...]
- 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for 3 of 4 residents reviewed for hospitalizations. (Resident R1, R59, and R246)
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of clinical record, review of facility documentation and review of facility policy, it was determined that the facility failed to ensure that a resident was transfer into bed timely as prefer by the resident for one of 21 residents sampled residents for activities of daily living (Resident R246). Findings Include: Review the policy title Activates of Daily Living (ADLs), supporting that was revised on March on 2018, revealed that on residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) Review of Resident R246's Minimum Data Set (MDS- assessment of resident's needs) dated January 6, 2025 revealed that the resident had a BIMS (Brief Interview of Mental Status) of 14, which indicated that the resident was cognitively intact. [...]
- C
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on facility documentation and staff interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for 21 of 21 sampled residents.
September 24, 2024Complaint inspection · 1 citation
- 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 clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate discharge notices were provided to the State Office of the Long-Term Care Ombudsman for two of five months reviewed (June and July 2024).
May 6, 2024Standard inspection · 7 citations
- 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 review of clinical records, review of facilitypolicy and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan related to respiratory care for one of 21 residents reviewed. (Resident R102)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on a review of clinical records, review of facility policy and staff interviews, it was determined that the facility failed to follow physician orders related to congestive heart failure protocol for one of eight sampled residents (Resident R 72) to monitor resident's daily weights and notify the medical doctor if any weight gain.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident's wander guard was functioning for the resident who is at risk for elopement for one of the one resident reviewed (Resident R89 and failed to ensure hot beverage temperatures were monitored on one of three nursing units (3rd floor dining room).
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for one four residents reviewed for nutritional status (Resident R39). Findings Include: Review of facility policy Weight Assessment and Intervention, revised March 2022, revealed undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change have been met. The evaluation includes, but not limited to, the resident's target weight range, and the resident's calorie, protein, and other nutrient needs compared with the resident's current intake. [...]
- 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 clinical record review and staff interviews, it was determined that the facility failed to ensure a resident's medication regimen was free from potential unnecessary medications for one of five residents reviewed. (Resident R 72).
- 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 review of the facility policy, observation, and staff interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with professional standards, and to discard expired medications in accordance with professional standards, for one of four medication carts observed (Middle Cart of Second Floor).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related to the processing of linens.
July 13, 2023Standard inspection · 7 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on observations, interviews, review of clinical records and facility documentation, it was determined that the facility failed to ensure a complete and accurate investigation to rule out abuse for two bruises of unknown origin for one out of 28 residents reviewed (Resident R43).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews with facility staff, review of clinical records and facility documentation, it was determined that the facility failed to ensure that two bruises of unknown origin were reported to the State Survey Agency for one out of 28 residents reviewed (Resident R43).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on the review of the clinical record an interviews with staff it was determined that the facility failed to ensure complete and accurate resident assessments for one out of 28 residents reviewed (Resident R12) Findings Include: Review of the July 2023 physician orders for Resident R12 included the following diagnosis: irritable bowel syndrome; hypertension (high blood pressure); osteoporosis (a disease that weakens the bones), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation on July 10, 2023, at 11:12 a.m. Resident R12 was observed in her room during an interview. [...]
- 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 review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure residents received care and services to maintain or improve mobility for two of four residents reviewed for positioning/mobility (Resident R24 and R16). Findings Include: Review of facility policy Restorative Nursing Services revealed residents will receive restorative nursing care as needed to help promote optimal safety and independence. Review of Resident R24's comprehensive Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact and had diagnoses of arthritis (the swelling and tenderness of one or more joints) and difficulty in walking. Interview on July 11, 2023, at 10:55 a.m. [...]
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure foods were stored in accordance with professional standards for food service safety and that dishes were cleaned under sanitary conditions. Findings Include: Review of facility policy Food and Supply Storage revealed all food shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Staff should cover, label, and date unused portions and open packages. Foods past the use-by date should be discarded. Further review of facility policy revealed foods should be stored in their original packages. Foods that must be opened must be stored in NSF (National Sanitation Foundation) approved containers that have tight fitting lids. Label both the bin and the lid and hang scoops. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteased on observation, review of policies and procedures, review of the Centers for Disease Control (CDC) guidelines, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the appropriate hand hygiene techniques and cleaning techniques for medical equipment on three of the five Medication Administration Reviews (R26, R34, and R44).
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, and staff and resident interview, it was determined facility did not maintain an effective pest control program so that the facility is free of pests and rodents one one of four units observed (unit 2 East)
Fire safety inspections
5 fire safety citations on file: 2 on March 6, 2025, 2 on May 6, 2024, 1 on July 13, 2023.
Every fire safety citation5 citations
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 6, 2025 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · March 6, 2025 · 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 6, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · May 6, 2024 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 13, 2023 · Corrected (the home has a date of correction)