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
January 15, 2026Standard inspection · 3 citations
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's preference and did not respond timely to resident's request for a Coronavirus Disease 2019 (COVID-19) booster vaccine for 1 of 4 residents reviewed for choices, of a total sample of 40 residents, (#113).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate documentation for application and removal of Thromboembolic Deterrent (TED) hose for 1 out of 1 residents sampled for application of TED hose, of a total sample of 40 residents, (#45).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate hand hygiene during medication administration and failed to sanitize equipment between residents per infection control standards to prevent cross-contamination and the spread of infection, for 1 of 4 nurses reviewed for medication administration.
April 18, 2024Standard inspection · 12 citations
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available on 2 of 3 units to meet residents' needs related to timely administration of scheduled medications, (Cliffstone and Pebblestone).
- 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 beverages and dishware were stored and served in a safe and sanitary manner to prevent foodborne illness.
- 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 record review, the facility failed to promote dignity in dining for 3 of 3 residents reviewed for dignity, of a total sample of 46 residents, (#77, #86, and #265).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was conducted and failed to obtain a physician's order for self-administration of medication for 1 of 10 residents reviewed for choices, of a total sample of 46 residents, (#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 observation, interview and record review, the facility failed to revise care plans to reflect accurate, appropriate, and individualized interventions related to showers/bathing and eating needs for 3 of 8 residents reviewed for activities of daily living (ADLs), of a total sample of 46 residents, (#31, #77 and #86).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, and obtain physician orders for treatment of non-pressure related skin conditions for 2 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 46 residents, (#42, & #56).
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Occupational Therapy (OT) recommendation for Restorative Nurse Program (RNP) for Range of Motion (ROM) was initiated and maintained for 1 of 1 resident reviewed for limited ROM, of a total sample of 46 residents, (#47).
- 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 therapy was administered per physician orders for 2 of 2 residents reviewed for oxygen therapy, of a total sample of 46 residents, (#14 and #58).
- 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 medications were administered within the designated guidelines, and per professional standard and practices, for 2 of 7 residents observed during medication administration, of a total sample of 46 residents, (#30, & #90).
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained for self administration of medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment while handling linens to prevent cross-contamination and spread of infection and failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's bathroom was adequately equipped to allow residents to call for staff assistance through a communication system in 1 of 6 resident rooms reviewed for environmental status, (room [ROOM NUMBER]).
October 26, 2023Standard inspection, Complaint inspection · 4 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was conducted for 1 of 1 resident of a total sample of 44 residents, (#151).
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized activity program based on preferences and plan of care was provided for 1 of 2 dependent residents reviewed for Activities, of a total sample of 44 residents, (#73).
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Midline intravenous dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed of a total sample of 44 residents, (#152).
- C
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview, and record review, the facility failed to ensure binding arbitration agreements explicitly granted the resident or their representative the right to rescind the contract within 30 calendar days of signing for 2 of 3 residents reviewed for arbitration agreements, (#202, #250).
Fire safety inspections
6 fire safety citations on file: 3 on January 15, 2026, 1 on April 18, 2024, 2 on October 26, 2023.
Every fire safety citation6 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 15, 2026 · 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 · January 15, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · October 26, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 26, 2023 · Corrected (the home has a date of correction)