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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
6D
2E
0F
Potential for minimal harm
0A
0B
1C
August 20, 2025Standard inspection · 4 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 provide a resident appropriate care and services for 1 of 1 resident reviewed for hospitalizations. The resident was not thoroughly assessed, physician's orders were not followed, and staff were not adequately trained to provide care of a resident with a recent vascular stent placement. This deficient practice resulted in the resident being hospitalized . (Resident 89)
- 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for dialysis. Care plans lacked resident specific diagnoses and interventions. (Resident 1, Resident 33, Resident 54, Resident 55, Resident 86)
- 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 and interview, the facility failed to ensure food was served in accordance with professional standards for 1 of 1 kitchen observed. Staff picked food up with soiled gloves, placed on top of resident's food, and served plate to residents. (Kitchen)
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's antipsychotic was changed without attempts of non-pharmacological interventions, and received more than the recommended dose of an antipsychotic medication when switching from one antipsychotic medication to another. (Resident 33)
July 1, 2024Standard inspection · 3 citations
- 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 who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for receiving oxygen therapy. A resident's oxygen concentrator and portable oxygen tank were not set at the ordered Liters Per Minute (LPM). (Resident 13)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents observed for a medication pass and 1 of 3 observed for incontinence care. During a med pass, pills were dropped on the medication cart and administered to a resident. Staff did not use hand hygiene between glove changes during care. (Resident 35, Resident 9)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Posted Nurse Staffing sheets contained the correct information daily for 1 of 6 days reviewed during the survey. (6/24/24)
April 4, 2023Standard inspection · 3 citations
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the resident right to be free of chemical restraint for 1 of 6 residents reviewed for falls. An anti-anxiety medication (lorazepam) was used as a chemical restraint to control the resident's behaviors in an effort to keep them from falling. (Resident 47)
- 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 a person-centered care plan was in place or revised to meet the resident's needs for 3 of 3 residents reviewed for developmentally disabled individuals. (Resident 39, Resident 34, Resident 3)
- 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 and interview, the facility failed to provide proper storage of medications in 1 of 2 medication storage rooms, 1 of 1 IV (intravenous) storage cart, and 1 of 6 medication carts. Loose pills were found in the bottom of the medication cart drawers. Expired IV fluid bags were stored in the IV treatment cart located within the storage room. (100 Hall and 600 Hall)
Fire safety inspections
16 fire safety citations on file: 1 on August 20, 2025, 8 on July 1, 2024, 7 on April 4, 2023.
Every fire safety citation16 citations
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 20, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · July 1, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 1, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · July 1, 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 · July 1, 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 · July 1, 2024 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · July 1, 2024 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 1, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · July 1, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 4, 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 · April 4, 2023 · Waiver
- E
Have properly located and lighted "Exit" signs.
K 293 · April 4, 2023 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 4, 2023 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · April 4, 2023 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · April 4, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 4, 2023 · Corrected (the home has a date of correction)