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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
1E
3F
Potential for minimal harm
0A
0B
0C
February 24, 2022Standard inspection · 3 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and review of the facility's food contract company's policy, Bulk Food - Delivery and Usage, the facility failed to ensure food with an expired use by date was discarded, placing 114 of 117 residents in the facility at risk for foodborne illness if served.
- D
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 record review, observation, interviews, and review of a facility policy titled, Catheter Care, the facility failed to ensure thorough cleaning of the penis during indwelling urinary catheter care for Resident Identifier (RI) #86, increasing the resident's risk for a urinary tract infection (UTI). The deficient practice affected RI #86, one of two residents sampled with an indwelling urinary catheter.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews,the facility failed to ensure: 1) Resident Identifier (RI) #223's oxygen was administered in accordance with the physician's order; and 2) RI #220's nebulizer mask and tubing was stored in a manner to prevent potential contamination when not in use. This deficient practice affected RI #223 and RI #220, two of four residents sampled for respiratory care.
June 6, 2019Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interviews and a review of the 2017 Food and Drug Administration Food Code, and facility policies related to Food Storage, the facility failed to: 1) completely air dry utensils, dishes and trays prior to storage and use; 2) consistently label food with preparation and use-by date (UBD) and discard food in a timely manner; 3) completely cover refrigerated food prior to storage; 4) ensure milk was stored in a manner to retain a recommended safe temperature of 41 degrees or less on the 6/4/19 lunch tray line; and hot food was maintained above 135 degrees F on the 06/05/19 tray line; 5) wash hands between dirty and clean tasks; and 6) maintain frozen food in a solid state during storage. These infractions had the potential to affect all 153 residents for whom meals were prepared and served at the time of this survey. Findings Included: [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interviews and a review of the 2017 Food Code, the facility failed to ensure the Hot Box consistently maintained temperatures above 135 degrees Fahrenheit (F) for the storage of foods to be served from the 06/05/19 supper meal. This had the potential to affect all 153 residents who received special food requests (such as sweet potato fries, fried fish, grilled cheese sandwiches) or planned (replacement) food added to the line as needed. Findings Included: The 2017 Food and Drug Administration Food Code, regulation #3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding specifies under (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . [...]
- 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 observation, interviews, record review and review of a facility policy titled, Enteral Tube Feeding via Continuous Pump, with a revised date on March 2015, the facility failed to ensure licensed staff applied a label, with required information, onto Resident Identifier (RI) #110 and RI #351's tube feeding bottles. This affected two of three residents observed for tube feedings on one of three days of the survey.
- 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 observation and interview, the facility failed to ensure RL(Room Locator) #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12, did not have a toilet with exposed rusty bolts. This affected resident bathrooms on 4 of 9 halls of the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, medical record review, and a review of the facility's policies titled, Personal Protective Equipment - Gloves and Handwashing / Hand Hygiene, the facility failed to ensure nursing staff wash their hands: 1. after removing gloves; 2. before leaving the resident's room; 3. after cleaning stool from a resident's buttocks, and 4. touching clean items, such as a new container of perineal wipes and a clean brief, while providing incontinence care to Resident Identifier #137. This affect one of three observations of incontinence care. Findings Include: A review of the facility's policy titled, Personal Protective Equipment - Gloves, with a revised date of July 2009, revealed: Policy Statement Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Policy Interpretation and Implementation . 8. [...]
June 21, 2018Standard inspection · 3 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interviews, and review of a facility policy titled Main Dining Room Meal Service Assistance, the facility failed to ensure Resident Identifier (RI) #84 did not have to wait for his/her supper meal on 6/19/18 while other residents at the tables were already dining. This affected one resident, seated at one of 12 tables, in the main dining room for the supper meal on 6/19/18.
- 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 interview, record review, and review of the facility policy titled Use of Side Rails, the facility failed to ensure an individualized plan of care that addressed the use of top 1/4 (quarter) side rails was developed for Resident Identifier (RI) #66. The facility further failed to ensure a urinary catheter care plan was developed for RI #89. This affected two of 32 sampled residents whose care plans were reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, interviews, and review of the facility's policies titled . Infection Control and Standard Precautions, the facility failed to ensure Resident Identifier (RI) #31's catheter tubing and bag were not directly on the floor. Further, the facility failed to ensure Certified Nursing Assistants (CNAs) removed their gloves and washed their hands after providing catheter care to RI #76, before touching the tube feeding pump, placing a clean pad under the resident, and touching the resident's body. This affected two of four residents sampled for catheters.
Fire safety inspections
6 fire safety citations on file: 1 on February 24, 2022, 2 on June 6, 2019, 3 on June 21, 2018.
Every fire safety citation6 citations
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · February 24, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2019 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 6, 2019 · Corrected (the home has a date of correction)
- D
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 · June 21, 2018 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 21, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 21, 2018 · Corrected (the home has a date of correction)