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 63 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
35D
13E
7F
Potential for minimal harm
0A
0B
4C
March 12, 2026Standard inspection, Complaint inspection · 42 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to protect the resident from physical abuse while obtaining a urine sample that resulted in hospitalization, thus resulting in the determination of Immediate Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #42. After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm.
- J
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to keep the resident from being physically restrained while obtaining a urine sample that resulted in hospitalization, thus resulting in the determination of Immediate Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #42, (R42). After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm.
- J
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to prevent an allergic reaction to a documented food allergy which resulted in the resident requiring emergency medical treatment, thus resulting in a determination of Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #43. After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm.
- G
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to uphold a resident's right to refuse care and treatment causing harm and resulting in a hospitalization for one of 36 residents in the survey sample, Resident #42.
- F
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain emergency medical equipment in a sanitary manner and ensure the supplies on the emergency medical cart were not expired, for one of one unit. Observation was made on [DATE] at 12:13 p.m. of the emergency medical cart (crash cart) on the health care unit. The following observations were made:Oxygen tank was 2% full, nearly empty. Top of the cart:Suction machine was not covered, only a mesh covering so air and dust can get through. There was no oxygen mask, no nasal cannula or normal saline, per their list of required items. The Ambu bag (used for resuscitation) was not in a bag to protect it. Lubricating jelly - two packages that were expired [DATE] and one package with an unreadable expiration date.[NAME] suctioning catheter package had a rip in it, making it not sterile any longer. [...]
- F
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, and facility document review, the facility staff failed to ensure appropriate competencies for 15 of 15 nurses and for one of three CNA (Certified Nursing Assistant) records reviewed.
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of required CNA training for five of five CNA records reviewed: CNAs #5, #6, #7, #8, and #9.
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to review and revise the document with administrative staff changes and address the emergency equipment to address the emergent medical needs of the residents. The facility assessment, reviewed on 2/3/2025, documented in part, 6. Medical and non-medical equipment required: Facility has Hoyer lifts sliding boards, reais to toilet devices, grab bars, wheelchair accessible vans and buses for transportation, feeding tube equipment and bolus services, wheelchairs, specialty wheelchair cushions, air mattresses, nebulizer and oxygen services. The facility does not have access to rental c-pap and bi-pap machines. All new admissions after January 1, 2024, must provide their own devices and supplies (excluding distilled water). [...]
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to have evidence of QAPI (quality assurance and performance improvement) from July 2023 through December 2023.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to evidence the attendance at the QAPI (quality assurance and performance improvement) meetings for 2024.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to implement their policy to prevent abuse for one of 36 residents in the survey sample, Resident #42 and for four of five staff records reviewed, Licensed Practical Nurses #8, #9, #10 and #11.
- E
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 observations, staff interview facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for five of 36 residents in the survey sample, Resident #5, Resident #22, Resident #14, Resident #36 and Resident #24.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to follow the physician's order for three of 36 current residents in the survey sample, Residents #16, #24 and #5.
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, resident interview, and clinical record review, the facility staff failed to provide parenteral catheter care for four of 36 residents in the survey sample, Residents #2, #6, #25, and #22.
- 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, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen.
- E
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to follow state regulations at the time of hire for four of five staff records reviewed, LPN (licensed practical nurse) #8, LPN #9, CNA (certified nursing assistant) #10, and CNA #11.
- E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for five of ten staff records reviewed, CNA (certified nursing assistant) #5, RN (registered nurse) #1, OSM (other staff member) #3, a speech and language pathologist, OSM #4, a dietary aide, and OSM #5, a housekeeper.
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to provide required training for five of five CNA (certified nursing assistant) records reviewed, CNAs #5, #6, #7, #8, and #9.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to promote dignity and respect for one of 36 residents, Resident #5.
- 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 staff interview, facility document review and clinical record review, the facility staff failed to notify the physician and/or the responsible party when medications are not available for administration for one of 36 residents in the survey sample, Resident #24.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility failed to maintain an accurate MDS (Minimum Data Set) record for 1 of 36 residents in the survey sample, Resident #25.
- 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 staff interview, facility document review, and clinical record review, the facility staff failed to implement the baseline care plan for one of 36 residents in the survey sample, Resident #34.
- 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 staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 36 residents in the survey sample, Resident #36.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow professional standards of practice for one of 36 residents in the survey sample, Resident #42.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide care and services to promote ADL (Activities of Daily Living) abilities for one of 36 residents in the survey sample, Resident #36.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for one of 36 residents, Resident #5.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to provide care and services for the assessment of a pressure injury for one of 36 residents in the survey sample, Resident #36.
- 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, staff interview and clinical record review, facility staff failed to provide care and services for an indwelling catheter for one of 36 residents in the survey sample, Resident #9.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 36 residents, Resident #22.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure required physician visits for one of 36 residents in the survey sample, Resident #7.
- D
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to verify licensure at the time of hire for two of three CNA (certified nursing assistant) records reviewed: CNAs #10 and #11.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration for one of 36 residents in the survey sample, Resident #24.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to prevent administration of unnecessary medications for three of 36 residents in the survey sample, Residents #34, #24, and #14.
- 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 observation, staff interview, facility document review, and clinical record review, the facility staff failed to store medications in a safe manner for two of 36 residents in the survey sample, Residents #6, and #25.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to obtain physician ordered laboratory tests for two of 36 residents in the survey sample, Residents #6 and #24.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for one of 11 residents in the survey sample, Resident #108.
- D
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for three of ten staff records reviewed, OSM (other staff member) #3 (a speech and language pathologist), CNA (certified nursing assistant) #6, and LPN (licensed practical nurse) #6.
- D
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.
- D
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.
- D
Provide training in compliance and ethics.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.
- D
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.
January 12, 2023Standard inspection · 16 citations
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop and/or provide residents and/or their responsible party, with a summary of the baseline care plan for five of 17 residents in the survey sample, Residents #176, #18, #177, #174 and #23.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as-needed pain medications for two of 17 residents in the survey sample, Residents #177 and #19.
- 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, staff interview, facility document review, and in the course of a complaint investigation, the facility staff failed to prepare, store, and serve food in a sanitary manner in one of one facility kitchen, and in one of one activity room refrigerator.
- 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 staff interview and clinical record review, it was determined that the facility staff failed to provide a written notice to the Office of the State Long-Term Care Ombudsman of a hospital transfer for one of 17 residents in the survey sample; Resident #10.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to follow professional standards of practice for medication administration for one of six residents in the medication administration task; Resident #174.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide clinical services in a manner to promote a resident's highest level of well-being for two of 17 residents in the survey sample, Residents #23 and #7.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility failed to follow and clarify an order for oxygen for one of 17 residents in the survey sample, Resident #17.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to complete annual performance evaluations for two of five CNA (certified nursing assistant) employee records reviewed, CNAs #2 and #3.
- D
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 document review, it was determined that the facility staff failed to ensure a medication was available for one of six residents in the medication administration task; Resident #174.
- 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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to act upon pharmacy recommendations in a timely manner for one of 17 residents in the survey sample; Resident #19.
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on clinical record review, staff interview, and resident interview, it was determined that the facility staff failed to comply with all the requirements of a binding arbitration agreement for two of 17 residents in the survey sample; Residents #1 and #19.
- D
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on clinical record review, staff interview, and resident interview, it was determined that the facility staff failed to ensure the binding arbitration agreements contained explicit language for the selection of an arbitrator and venue, for two of 17 residents in the survey sample; Residents #1 and #19.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement a complete immunization program for one of five residents immunization record reviews, Resident #10.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to post the required nursing staffing information each shift for 30 of 30 days of records reviewed.
- C
Report COVID19 data to residents and families.
Inspectors wroteBased on clinical record review, staff interview, and facility document review it was determined the facility staff failed to evidence notification of facility COVID-19 activity to residents and/or responsible parties and families during active COVID-19 cases confirmed in the facility 12/8/2022-12/25/2022.
- C
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on staff interview and facility document review it was determined the facility staff failed to evidence COVID-19 testing of staff during an outbreak of active COVID-19 cases confirmed in the facility 12/8/2022-12/25/2022 for one of 3 staff sampled, RN (registered nurse) #3.
August 12, 2021Standard inspection · 5 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to dispose of garbage in a sanitary manner. On 8/10/21, the facility staff failed to ensure trash in the garbage compactor was covered. Multiple flies were observed flying above the trash.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for five of 17 residents in the survey sample, Residents #20, #22, #74, #13 and #8. The facility staff failed to obtain informed consent prior to the use of bed rails for Residents #20, #22, #74, #13 and #8.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for six of 17 residents in the survey sample, Residents #18, #20, #22, #74, #13 and #8.
- 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 observation, staff interview and facility document review, it was determined that the facility staff failed to store medications according to professional standards for one of one medication room. Two expired vials of Aplisol PPD (purified protein derivative) solution (1) was stored in the medication room refrigerator available for resident use.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post current nurse staffing information. Nurse staffing information for 8/10/21 was not posted on 8/10/21. Instead, nurse staffing information for 8/8/21 was posted.
Fire safety inspections
3 fire safety citations on file: 1 on March 12, 2026, 2 on August 12, 2021.
Every fire safety citation3 citations
- D
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 · March 12, 2026 · Corrected (the home has a date of correction)
- D
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 · August 12, 2021 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 12, 2021 · Corrected (the home has a date of correction)