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 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
36D
3E
1F
Potential for minimal harm
0A
0B
0C
March 26, 2026Complaint inspection · 2 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to treat a wound when first discovered for one of one resident (R1) when the facility staff identified a wound on 3/16/26, applied a dressing, and then notified the provider and initiated treatment on 3/23/26.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are accurately documented for five of six residents (R1, R2, R3, R5, and R6) when their weekly bath audits did not indicate wounds that they were being treated for.
March 12, 2026Standard inspection, Complaint inspection · 9 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and document review the facility failed to electronically submit direct care staffing information (including agency and contract staff) per day, based on payroll and other verifiable and auditable data to Centers for Medicare and Medicaid Services (CMS). The had the ability to impact all 171 residents residing at the care facility.
- 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 interview and document review, the facility failed to notify the attending physician of a change in condition for 1 of 1 resident (R181) reviewed for discharge process.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and document review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers to an acute care facility on an emergent basis, and failed to ensure a written notice of bed hold was provided and documented in the electronic medical record (EMR) for 2 of 2 residents (R10, R17) reviewed for hospitalizations.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning for 3 of 5 residents (R5, R8, and R25) reviewed for MDS accuracy.
- 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 interview, observation and document review, the facility failed to ensure a comprehensive care plan was developed and implemented for 1 of 1 resident (R13) reviewed for pain management.
- 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 observation, interview, and document review, the facility failed to revise the care plan to include a comprehensive pain management plan for 2 of 3 residents (R6, R42) reviewed with a history of pain.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and document review, the facility failed to ensure a resident was reassessed and failed to implement new interventions to prevent skin breakdown after developing a stage III pressure injury while a resident at the facility for 1 of 2 residents (R123) reviewed for pressure injuries.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and document review the facility failed to provide assessments and routine dental services to 2 of 2 residents (R87, R152) reviewed for dental care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 1 of 1 residents (R9) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Facility also failed to ensure hand hygiene was performed for 1 of 2 residents (R73) reviewed for transmission-based precautions (TBP). Findings Include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for EBP included: [...]
June 26, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. In addition, the facility failed to protect 1 of 3 residents (R1) while the investigation was conducted.
March 27, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper enhanced barrier precautions (EBP), glove use, and hand hygiene was performed during incontinence care for 1 of 3 (R1) residents reviewed for incontinence care.
January 9, 2025Standard inspection, Complaint inspection · 12 citations
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and document review, the facility failed to assess and, if able, implement interventions to ensure privacy was maintained during provision of wound care for 1 of 1 resident (R108) reviewed who expressed being claustrophobic and not wanting their doorway closed to public view. In addition, the facility failed to ensure resident' identifiable personal care information was kept secured and out of public view when stored on 1 of 1 mobile medication carts. This had potential to affect 1 of 1 residents and 14 residents (R53, R21, R74, F85, R82, R65, R7, R38, R103, R147, R154, R116, R102 and R128) of the second floor whose information was listed on an exposed care sheet.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care-planning process (i.e., meeting) was implemented to ensure continuity of care and promote participation in care-planning for 1 of 2 residents (R222) reviewed for participation in care-planning.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and document review, the facility failed to ensure a quarterly Minimum Data Set (MDS) was completed in a timely and/or comprehensive manner to facilitate accurate evaluation of resident' conditions for 2 of 3 residents (R50, R108) reviewed for MDS accuracy.
- 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 interview, observation and document review, the facility failed to ensure comprehensive care plans were developed and maintained to facilitate person-centered care for 2 of 2 (R142, R139) residents reviewed for care planning. R142 R142's quarterly Minimum Data Set (MDS) dated [DATE], indicated R142 was cognitively intact, had no behaviors, did not refuse cares, needed set-up for oral hygiene and eating, and required maximal assistance with mobility and all activities of daily living (ADL). The MDS also indicated R142 had no pressure ulcers. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e., nail care) was completed to reduce the risk of complication (i.e., scratches, infection) for 1 of 3 residents (R47) reviewed for activities of daily living (ADL) and whom was dependent on staff for their nail care.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interview, and document review, the facility failed to comprehensively reassess and, if needed or able, develop interventions to ensure activities-of-interest were advertised, offered and/or provided for 1 of 2 residents (R222) reviewed for activities and whom resided on the short-term unit (i.e., TCU).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess, care plan, and implement interventions to prevent recurrent pressure ulcers for 2 of 2 resident (R39 and R142) who had a history of pressure ulcers.
- 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, interview and document review, the facility failed to ensure bladder and bowel incontinence was comprehensively assessed and interventions developed to promote continence for 2 of 2 resident (R142, R139) reviewed for incontinence cares.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and document review, the facility failed to ensure an antibiotic without an end date was monitored and evaluated for the appropriateness of its continued use for 1 of 1 residents (R107) reviewed for antibiotic administration.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview and document review, the facility failed to ensure an order for laboratory services was followed through and completed for 1 of 1 resident (R145) reviewed for laboratory services who had Clostridium difficile (C. diff; bacteria which can cause diarrhea, abdominal pain and cramping, fever, nausea, and dehydration.)
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide the ordered drink consistency for 1 of 1 residents (R82) reviewed for dining.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview the facility failed to follow infection control standards of practice for the cleaning of hard surfaces in the resident room for 1 of 1 residents (R39) on enhanced barrier precautions (EBP) reviewed for infection control practices.
February 7, 2024Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess a resident, reevaluate interventions, or make changes to a care plan after a fall for one of three residents (R1) reviewed for falls when R1 had a previous fall with a history of letting go of the EZ stand lift grab bars. R1's recent fall resulted in fractures of her neck and back.
January 30, 2024Complaint inspection · 2 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a a resident was treated in a dignified manner when he received a haircut from a nursing assistant (NA)-B without permission for 1 of 3 residents reviewed for dignity.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and document review, the facility failed to provide the opportunity to participate in the care planning process, be included in the decisions about care, treatment and/or interventions in the required quarterly time frame for 1 of 3 resident (R3) reviewed for care planning.
January 12, 2024Complaint inspection · 6 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess fall risk and implement appropriate fall interventions to decrease the risk for 2 of 3 residents (R1, R2) with falls. This resulted in harm for R1 who sustained two serious head injuries, was transferred to the hospital, and later died as a result of his injuries.
- D
Give residents a notice of rights, rules, services and charges.
Inspectors wroteBased on interview and document review, the facility failed to ensure a non-English speaking resident was provided with appropriate interpretive services for 1 of 3 residents (R1). In addition, the facility failed to reevaluate the effectiveness of the services offered, allowing them to be fully informed about their health status in an emergent situation.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and document review, the facility failed to complete a thorough investigation regarding a fall for 1 of 1 residents (R1) reviewed for falls.
- 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 interview and document review, the facility failed to develop comprehensive care plans including a toileting plan of care, a pressure sore plan of care, and a skin integrity plan of care for 3 of 3 residents (R1, R4, R5) reviewed for comprehensive care planning.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess impaired skin integrity and initiate and evaluate appropriate interventions for 1 of 1 residents (R5) reviewed for non-pressure related skin injuries.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and document review, the facility failed to perform comprehensive skin assessments and provide interventions for pressure ulcer prevention and treatment for 2 of 3 residents (R4, R1) reviewed for pressure ulcers.
November 30, 2023Standard inspection, Complaint inspection · 8 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a community-use available glucometer was properly cleaned and disinfected between patient' use for 1 of 1 resident (R107) observed to have their blood glucose checked with the device. This had potential to affect 12 of 12 residents identified to reside on the 200 East Unit and have diabetes mellitus. In addition, the facility failed to ensure medical supplies with potential for blood-borne cross contamination were appropriately stored away from patient living areas for 1 of 1 resident (R44); and failed to ensure posted transmission-based precautions were consistently implemented to reduce to risk of infectious spread for 1 of 1 resident (R18) identified to be on such precautions. This had potential to affect 25 of 25 residents identified to reside on the same unit.
- 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 observation, interview, and document review, the facility failed to ensure resident' responsible parties were notified in a timely manner with abnormal lab values and corresponding medical treatment being implemented for 1 of 2 residents (R173); and with the development of a skin ulcer which required medical care and treatment for 1 of 2 residents (R49) reviewed for notification of change.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and document review, the facility failed to ensure a significant change in status assessment (SCSA) was completed within required timeframe to help facilitate timely person-centered careplanning for 1 of 2 residents (R144) reviewed for Minimum Data Set (MDS) accuracy.
- 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 interview and document review, the facility failed to develop a comprehensive care plan, including with resident-specific interventions, to meet the known and identified behavioral expressions and needs for 1 of 1 resident (R78) reviewed with cognitive impairment who, at times, refused personal care.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and document review, the facility failed to ensure routine bathing was offered or provided to promote good hygiene for 1 of 5 residents (R78) reviewed for activities of daily living (ADLs) and who was dependent on staff for their cares.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review, the facility failed to implement care plan interventions for 2 or 2 residents (R73, R83) reviewed for falls.
- 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 observation, interview and document review, the facility failed to ensure non-pharmacological interventions were care planned, attempted, and recorded before the administration of as-needed (PRN) psychotropic medication to reduce the risk of complication for 1 of 1 residents (R38) reviewed for unnecessary medication use.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and provided in a timely manner for 2 of 5 residents (R18, R140) reviewed for immunizations.
September 28, 2023Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteThe facility failed to thoroughly investigate a resident's ability to consent to consensual sexual activities for 2 of 2 residents (R3 and R4) reviewed for an allegation of abuse when the residents had impaired cognition, impaired communication, and required extensive assistance for all their activities of daily living (ADLS.)
Fire safety inspections
8 fire safety citations on file: 1 on March 12, 2026, 1 on January 9, 2025, 6 on November 30, 2023.
Every fire safety citation8 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 12, 2026 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · January 9, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 30, 2023 · 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 · November 30, 2023 · Waiver
- E
Have exits that are accessible at all times.
K 271 · November 30, 2023 · Waiver
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 30, 2023 · Waiver
- E
Have restrictions on the use of highly flammable decorations.
K 753 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · November 30, 2023 · Corrected (the home has a date of correction)