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 17 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
7E
0F
Potential for minimal harm
0A
0B
0C
February 22, 2024Standard inspection · 7 citations
- 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 clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 16 residents in the survey sample, Resident #93.
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement a complete pain management program for two of 16 residents in the survey sample, Residents #1 and #8.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for one of one dialysis residents in the survey sample, Resident #93.
- E
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 staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication, for one of 16 residents in the survey sample, Resident #26.
- 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, staff interview, and facility document review, it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to promote dignity for one of 16 residents in the survey sample, Resident #18.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices for one of 16 residents in the survey sample, Resident #35.
April 28, 2022Standard inspection · 2 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The facility staff failed to date and dispose of expired or opened food during the facility task kitchen observation on 4/26/22 at 4:17 PM in one of three kitchen areas.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and staff interview the facility staff failed to follow infection control practices for one of seven residents in the medication administration observation, Resident # 34 (R34). The facility staff placed their ungloved finger on the inside of the medication cup while administering medications to (R34).
March 26, 2021Standard inspection · 8 citations
- 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, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner. In the walk in refrigerator, a bottle of zesty orange sauce without an open or use by date and a ten pound container of sweet-and-sour duck sauce, was observed available for use past the labeled use by date of 2/21/21 on the container.
- 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, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to implement or develop a comprehensive care plan for three of 24 residents in the survey sample, Residents # 16, # 8 and # 12. 1. The facility staff failed to implement Resident # 16's comprehensive care plan for the use of non-pharmacological interventions prior to the administration of the physician prescribed as needed pain medication, Tylenol [1]. 2. The facility staff failed to develop a comprehensive care plan for the use of an incentive spirometer [1] for Resident # 8. 3. The facility staff failed to develop a comprehensive care plan to address Resident #12's use of a sling and a surgical wound dressing present on readmission.
- 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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 24 residents in the survey sample, Resident #6. The facility failed to update Resident #6's comprehensive care plan to address a UTI (urinary tract infection) and treatment with an antibiotic.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the the facility staff failed to follow professional standards of practice for transcribing physician orders into the clinical record for one of 24 residents in the survey sample, Resident #12. The facility staff failed to transcribe and Resident #12's hospital physician's orders for non-weight bearing status of her right arm, sling and surgical wound at the time of her readmission.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provided respiratory care, consistent with professional standards of practice and the plan of care for one of 24 residents in the survey sample, Resident #8. The facility staff failed to store Resident #8's incentive spirometer in a sanitary manner when not in use.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to implement a complete pain management program consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 24 residents in the survey sample, Resident # 16. The facility staff failed to conduct a pain assessments and failed to attempt/provide non-pharmacological interventions prior to the administration of physician prescribed as needed pain medication Tylenol to Resident #16 on multiple occasions.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement a comprehensive program for dialysis services for one of 24 residents in the survey sample, Resident #6. The facility staff failed to obtain physicians' orders for Resident #6's dialysis services and for assessment of the resident's dialysis access site, and failed to maintain regular communication with the dialysis provider.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to ensure the medication regimen was free from unnecessary medications for one of 24 residents in the survey sample, Resident # 16. The facility staff failed to conduct a pain assessment and failed to attempt / provide non-pharmacological interventions prior to the administering as needed pain medication Tylenol, to Resident #16.
Fire safety inspections
5 fire safety citations on file: 1 on February 22, 2024, 2 on April 28, 2022, 2 on March 26, 2021.
Every fire safety citation5 citations
- 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 · February 22, 2024 · Waiver
- D
Provide properly protected cooking facilities.
K 324 · April 28, 2022 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 28, 2022 · 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 · March 26, 2021 · 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 26, 2021 · Corrected (the home has a date of correction)