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
0G
0H
0I
Potential for more than minimal harm
10D
0E
0F
Potential for minimal harm
0A
0B
0C
September 5, 2024Standard inspection · 3 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one resident (# 14) of eight residents sampled, was provided the opportunity to participate in care planning.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for four (#1,#5,#6,#8) of 23 residents sampled for PASRR
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. ensure oxygen administration orders were followed for two (#239, #2) of seven residents who received oxygen therapy.
March 2, 2022Standard inspection · 2 citations
- 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 observation, interview, and record review the facility failed to implement the comprehensive care plan related to hearing for one resident (#15) of one resident sampled for hearing.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was less than 5.00%. A total of twenty-six medications were observed administered, and four errors were identified for three residents (#14, #25 and #28) of six residents observed. These errors constituted a medication error rate of 15.38%.
March 5, 2020Standard inspection · 5 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, resident record review and staff/resident interviews, the facility failed to honor/maintain residents in a respectful manner for 3 (#31, #19, and #99) related to: 1. Resident #31 observed four of four days (3/2/20 - 3/4/20) wearing a bright yellow wrist band that identified as Fall Risk; 2. Staff observed speaking to Resident #19 in a manner of non-caring and disinterest; 3. Staff observed referring to Resident #99 as Feeder during tray pass; 4. Staff not knocking/announcing prior to entering resident rooms four of four days observed (3/2/20 - 3/5/20); and 5. Staff not wearing name badges routinely in order to identify the staff member to residents providing care/services.
- D
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 interview and record review of the Grievance Log, the facility failed to ensure that that a nursing/customer service concern was addressed in a timely manner for one (#98) out of thirty sampled residents. Findings Included: On 3/3/2020 at 12:40 p.m., a family interview was conducted with Resident #98's stepdaughter, as she spoke about the lack of care he had received at the facility. She stated call lights were not answered timely. And when a nurse came in the bedroom, she was told about a toileting concern. She shut the light off and said someone will return. Well, no one did. We had to put the call light back on. Another concern she spoke about was when her stepfather was given his medications. She said, I was there when she gave them to him. She stated the nurse gave him too many pills at a time. He began to cough and choke. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the monitoring and safety for one of thirty sampled residents (#14), related to fall hazards. Resident #14 who was a Fall Risk, and had a history of falls, was observed several times on different dates during (3/2/2020, and 3/3/2020), lying in bed with her legs hanging off and was dangerously close to falling off.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and medical record review, the facility did not ensure that the medication error rate was below 5 % for one (# 43) of 4 sampled residents who were administered medications. This resulted in 4 errors from 25 medication administration opportunities, for a medication error rate of 16%. Findings Included: On 3/2/2020 at 10:24 a.m., a medication administration was conducted with Licensed Practical Nurse Q (LPN Q). She stated, Today was the first day I have ever worked at the facility. The electronic medication administration (EMR) was red in color as LPN Q confirmed the medications were late. She was asked if any of the facility licensed staff had asked if she needed assistance; she looked at the surveyor and shook her head in the no gesture. LPN Q went on to say that she started the medication pass late. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, medical record review and contact precautions, the facility failed to ensure that contact precautions were utilized as posted for two (#40 & #29) of two residents who were on contact precautions. Findings Included: 1. On 03/02/20 09:51 a.m., Resident #40 was lying in his bed with his eyes closed. Home Health Aide (HHA M) was sitting in a chair at his bedside. HHA M was asked why she was wearing a gown and gloves. She said she was told she needed to wear them when she was in the room. The HHA spoke about being at the facility three days a week for twelve hours each day. She said the resident was confused and attempted to get out of bed unassisted. Outside of the doorway entrance, personal protective equipment (PPE) hung on the door, along with a posted sign that read Contact Precautions. Visitors must report to nursing station before entering. [...]
Fire safety inspections
8 fire safety citations on file: 2 on September 5, 2024, 1 on March 2, 2022, 5 on March 5, 2020.
Every fire safety citation8 citations
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 5, 2024 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · September 5, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 2, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 5, 2020 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 5, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2020 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 5, 2020 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 5, 2020 · Corrected (the home has a date of correction)