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 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
2E
0F
Potential for minimal harm
0A
0B
1C
March 17, 2026Standard inspection · 2 citations
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for 1 of 4 residents reviewed for PASARR. (Resident 13)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was held according to the physician's order for 2 of 2 residents reviewed for quality of care. (Resident 3 and 58) The deficient practice was corrected on 3/6/26, prior to the start of the survey, and was therefore past noncompliance.
June 5, 2025Complaint inspection · 1 citation
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff did not take and share unauthorized photos of a resident for 2 of 3 residents reviewed for privacy. (Resident B) The deficient practice was corrected on 5/8/25, prior to the start of the survey, and was therefore past noncompliance.
April 28, 2025Standard inspection · 5 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure the pre-admission screening and resident review (PASARR) was completed accurately for 2 of 5 residents reviewed for PASARR. (Resident 18 and 33)
- 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 interview and record review, the facility failed to ensure there was sufficient documentation to show a behavior care plan was prepared by an interdisciplinary team, which included the participation of the resident and the resident's representative prior to initiation and to ensure care plan meetings were conducted and documented for 3 of 8 residents reviewed for care plans. (Resident 2, 23 and 42)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's oxygen concentrator was turned on to deliver oxygen therapy according to the physician's order and failed to obtain a physician's order for the use of oxygen for 2 of 4 residents reviewed for respiratory care. (Resident 15 and 201)
- 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, interview and record review, the facility failed to ensure a medication was labeled with a resident's name in 1 of 2 medication carts and staff signed the narcotic count log during shift change in 2 of 2 narcotic books reviewed for medication storage. (boardwalk south and 200 south)
- D
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 ensure a resident's medical record was complete and accurately documented related to meal intakes for 1 of 1 resident reviewed for documentation. (Resident 2)
April 4, 2024Standard inspection, Complaint inspection · 9 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) options were documented as reviewed with the resident in the Electronic Health Record (EHR) and the resident choose correctly for 2 of 3 residents reviewed for beneficiary notices. (Resident 20 and I)
- 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 interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman when a resident was hospitalized for 1 of 3 residents reviewed for hospitalization. (Resident J)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order was transcribed correctly to the Medication Administration Record (MAR), to ensure a physician's order was followed, and to notify the physician when a physician's order was not followed for 1 of 1 resident reviewed for dialysis (Resident 25) and failed to monitor and document bowel movements for 2 of 5 residents reviewed for bowel and bladder function. (Resident F and G)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered according to an active physician's order, failed to administer oxygen at the specified flow rate once an order was obtained, and failed to label the oxygen tubing for 1 of 2 residents reviewed for respiratory care. (Resident 307)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility failed to ensure a lab was obtained according to the physician's order and prior to giving an antibiotic for 1 of 2 residents reviewed for antibiotics. (Resident I)
- 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 interview and record review, the facility failed to ensure a correct diagnosis was added to an antipsychotic order and to monitor for psychotic symptoms for 1 of 5 residents reviewed for unnecessary medications. (Resident 10)
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member had a valid nursing license for 1 of 21 nurses reviewed for current licenses. (Registered Nurse 9)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were handled in a sanitary manner for 1 of 7 residents observed for medication administration (Resident D) and failed to ensure staff transported clean linen/gowns in a manner which prevents contamination for 2 of 3 staff observed transporting linen. (Housekeeper 5 and CNA 4)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a current nurse staff posting was displayed daily at the beginning of each shift for 1 of 7 days reviewed for nurse staff posting. (3/27/24)
November 9, 2023Complaint inspection · 2 citations
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of property, specifically medications, when a Registered Nurse removed discontinued medications from the facility without consent and ordered medications without the authorization of a licensed medical provider and then removed them from the facility for 5 of 5 residents reviewed for misappropriation of property. (Resident 2, 3, 4, 5, and 6) The deficient practice was corrected on 11/02/23, prior to the start of the survey and was therefore past noncompliance.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to maintain a record of disposition/return of unused and discontinued medications to the pharmacy and failed to ensure a licensed physician or nurse practitioner authorized or prescribed medications for 5 of 5 residents reviewed for pharmacy services. (Resident 2, 3, 4, 5, and 6) The deficient practice was corrected on 11/02/23, prior to the start of the survey and was therefore past noncompliance.
Fire safety inspections
10 fire safety citations on file: 1 on April 28, 2025, 9 on April 4, 2024.
Every fire safety citation10 citations
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 28, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have an alternate power supply for its alarm system.
K 344 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · April 4, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 4, 2024 · 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 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 4, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 4, 2024 · Corrected (the home has a date of correction)