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 77 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
55D
21E
0F
Potential for minimal harm
0A
0B
0C
May 14, 2026Complaint inspection · 5 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after an injury occurred for one of four residents reviewed (Resident 1).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for wound care were followed for one of four residents reviewed (Resident 1).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of four residents reviewed (Resident 1). This deficiency is being cited as past non-compliance.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to drink in accordance with the resident's care plan for one of four residents reviewed (Resident 1). This deficiency is being cited as past non-compliance.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during wound care for one of four residents reviewed (Resident 1).
April 17, 2026Complaint inspection · 2 citations
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on review of facility policy, clinical records and grievances, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance for one of 7 residents reviewed (Resident 2).
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that the stove/oven was maintained in working condition in the kitchen.
February 4, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for two of four residents reviewed (Resident 3, 4).
January 2, 2026Complaint inspection · 2 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of policies, observations and staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure a safe route of egress through emergency exit doors for residents on two of three units ([NAME] and [NAME] units), which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death.
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of policies and employee job descriptions, as well as observations and staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical well being of residents in the facility by failing to ensure that emergency exit doors were accessible to residents, allowing egress to the outside during an emergency situation, placing the residents at risk for serious harm which created an Immediate Jeopardy situation.
November 20, 2025Standard inspection · 12 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 46 residents reviewed (Resident 67).
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to serve food that was palatable to residents.
- E
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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bell was within reach for one of 46 residents reviewed (Resident 85).
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for five of 48 residents reviewed (Residents 46, 68, 71, 83, 122).
- 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 clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement an individualized care plan for dental needs for one of 46 residents reviewed (Resident 89).
- 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 review of clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 46 residents reviewed (Resident 7).
- D
Provide appropriate foot care.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 46 residents reviewed (Resident 6).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from accidents that resulted in injury for one of 46 residents reviewed (Resident 46). This deficiency is being cited as past non-compliance.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 46 residents reviewed (Resident 67).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medications as ordered by the physician, resulting in a significant medication error for one of 46 residents reviewed (Resident 115).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
May 14, 2025Complaint inspection · 1 citation
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of eight residents reviewed (Resident 6).
April 30, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of four residents reviewed (Resident 1).
December 3, 2024Complaint inspection · 2 citations
- 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify to update the admitting facility with information about laboratory testing and results for one of three residents reviewed (Resident 2).
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of three residents reviewed (Resident 2).
October 9, 2024Standard inspection, Complaint inspection · 25 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for two of 61 residents reviewed (Residents 36, 68).
- E
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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide appropriate care to ensure that interventions were in place to prevent urinary tract infections for three of 61 residents reviewed (Residents 13, 80, 104) who had indwelling urinary catheters.
- E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 61 residents reviewed (Residents 88, 109) who had a feeding tube.
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed per facility policy for three of 61 residents reviewed (Residents 101, 104, 136).
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for three of 61 residents reviewed (Residents 8, 13, 61).
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record reviews and resident and staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 61 residents reviewed (Resident 84).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for three of 61 residents reviewed (Residents 19, 78, 108).
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 61 residents reviewed (Resident 59).
- 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for four of 61 residents reviewed (Residents 14, 17, 59, 101).
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a criminal background check prior to hire for one of three nurse aides reviewed (Nurse Aide 3).
- 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 clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for four of 61 residents reviewed (Residents 13, 88, 109, 131). This deficiency was cited as past noncompliance.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 61 residents reviewed (Residents 6, 13, 51, 78, 80, 88, 128).
- 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for two of 61 residents reviewed (Residents 70, 80).
- 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 61 residents reviewed (Residents 51, 80).
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on policy review, observations, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards regarding medication administration for two of 61 residents reviewed (Residents 47, 77).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding treatment administration were followed for one of 61 residents reviewed (Resident 80).
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on review of clinical records, as well as resident, family, and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of 61 residents reviewed (Resident 14).
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder for one of 61 residents reviewed (Resident 113).
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of facility policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for two of three nurse aides reviewed (Nurse Aides 8, 9).
- 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician responded timely to pharmacy recommendations for one of 61 residents reviewed (Resident 61).
- 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 facility policies, observations, and staff interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in one of two medication rooms reviewed (medication room on [NAME] unit), failed to discard an expired multi-dose inhaler in one of three carts reviewed ([NAME] long hall cart), failed to label an opened, multi-dose insulin vial in one of three carts reviewed ([NAME] long hall cart), and failed to ensure that medications were properly stored and labeled for two of 61 residents reviewed (Residents 78, 108).
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide adaptive eating equipment as ordered by the physician for one of 61 residents reviewed (Resident 42).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 61 residents reviewed (Resident 130). Findings Include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 130, dated August 6, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe) and gastroesophageal reflux disease (GERD - a chronic condition that occurs when stomach contents leak into the esophagus, causing irritation and other symptoms). [...]
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- 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 manufacturer's directions for use and observations, as well as staff interviews, it was determined that the facility failed to maintain two of three laundry dryers in safe operating condition.
September 11, 2024Complaint inspection · 3 citations
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for one of 15 residents reviewed (Resident 10).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 15 residents reviewed (Resident 10).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were performed during care for one of 15 residents reviewed (Resident 15).
July 3, 2024Complaint inspection · 3 citations
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on review of policies and clinical records, as well as staff and family interviews, it was determined that the facility failed to routinely conduct care plan meetings and invite the resident or representative to attend for one of six residents reviewed (Resident 6).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical records and facility assessment reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of six residents reviewed (Resident 4) who used an air mattress.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of established infection control guidelines and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of six residents reviewed (Residents 1, 4).
May 30, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of four residents reviewed (Residents 1, 2), and failed to ensure that verbal phone orders were written and followed for one of four residents reviewed (Resident 1).
May 1, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 10 residents reviewed (Resident 2).
March 5, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for one of 10 residents reviewed (Resident 5).
November 9, 2023Standard inspection, Complaint inspection · 15 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for three of 66 residents reviewed (Resident 7, 64, 97) and failed to ensure that physician orders were followed for one of 66 residents reviewed (Resident 90).
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status by failing to ensure timely notification of the physician for one of 66 residents reviewed (Resident 65). Findings Include: The facility's policy regarding food and nutrition anthropocentric (measurements), dated January 19, 2023, indicated that any resident with a weight change of 5 percent or more since the last weight assessment will be reweighed for confirmation and that interventions would be based on several things. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 66 residents reviewed (Resident 64).
- E
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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 66 residents reviewed (Resident 64).
- E
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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that dietary staff wore hair coverings that completely covered their facial hair during food handling and failed to store and prepare food in accordance with professional standards for food service safety by not dating opened food items and not storing food under sanitary conditions.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications for one of 66 residents reviewed (Resident 79), failed to ensure that proper infection control practices were followed for urinary catheter care for one of 66 residents reviewed (Resident 109), and failed to report COVID positive residents and staff to the Department of Health.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for four of 66 residents reviewed (Residents 26, 60, 93, 96).
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for two of 66 residents reviewed (Residents 23, 60).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 66 residents reviewed (Residents 30, 51, 60, 97).
- 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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 66 residents reviewed (Residents 23, 30).
- 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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 66 residents reviewed (Residents 90, 121).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation and failed to administer treatments per physician's orders for one of 66 residents reviewed (Resident 74).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of clinical record reviews and facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 66 residents reviewed (Resident 51).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 66 residents reviewed (Residents 81). Findings Include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated May 24, 2023, revealed that the resident was cognitively intact, was independent with daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 81, dated January 1, 2023, included an order for insulin aspart, inject 10 units subcutaneously (under the skin) each morning with breakfast. [...]
October 3, 2023Complaint inspection · 2 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in the hallways on the [NAME] nursing unit.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of nine residents reviewed (Resident 1).
Fire safety inspections
16 fire safety citations on file: 1 on January 5, 2026, 1 on November 24, 2025, 5 on November 20, 2025, 3 on October 9, 2024, 6 on November 9, 2023.
Every fire safety citation16 citations
- 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 · January 5, 2026 · Corrected (the home has a date of correction)
- E
Have a properly installed medical gas master alarm panel.
K 904 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 20, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 20, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 20, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 20, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · November 20, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 9, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 9, 2024 · Corrected (the home has a date of correction)
- C
Provide properly protected cooking facilities.
K 324 · October 9, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · November 9, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 9, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 9, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 9, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 9, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · November 9, 2023 · Corrected (the home has a date of correction)