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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
2E
1F
Potential for minimal harm
0A
0B
0C
August 15, 2024Standard inspection, Complaint inspection · 4 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, staff interviews and record review, the facility failed to maintain the kitchen and kitchen equipment in a sanitary and functional manner during two of four days observed (8/12/2024, 8/13/2024), related to; 1. Kitchen dish washing machine not operating per the machine's maintenance service specifications/recommendations; 2. Not maintaining ceiling vents above food preparation stations in a dust/debris free environment; and 3. Not maintaining the walk in freezer free from heavy ice build up on various boxes of food items.
- E
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review and interview, the facility failed to ensure two residents (#21 and #216) out of two residents with history of trauma had triggers identified to prevent re-traumatization.
- 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 observations, interviews and record review, the facility failed to ensure a quiet and homelike environment on one of four units (GNR 300), during three of four days observed (8/12/2024, 8/13/2024, 8/14/2024). It was observed and overheard a resident was yelling and causing loud noises for long periods of time and affecting Residents on the entire GNR 300 hallway to include Residents #32, #49, #15, #1, and 14.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to ensure two residents (Resident #98 and #260) of the five residents sampled for baseline care plans.
July 28, 2022Standard inspection · 3 citations
- E
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, interviews, and record review, the facility failed to follow their policy to 1. store medications appropriately in three of five (100-400 Hall) medication carts, failed to ensure controlled substances were appropriately stored in a locked drawer in one of two medications storage rooms (SSU Hall), and did not ensure expired tuberculin testing syringes were disposed of in one of two medication storage room refrigerators (100-300 Hall); 2. Failed to appropriately secure medications for two Residents (#67 and #334) of four residents.
- 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 observations, resident record, and interviews, the facility failed to develop care plan problem areas with interventions related to behaviors and the development of a potential rash for one (Resident #29) of thirty-eight sampled residents.
- D
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 interviews and record review, the facility failed to ensure behavior monitoring was in place for one (Resident #67) of three sampled residents on psychotropic medications. Findings Included: A review of admission records indicated Resident #67 was admitted on [DATE] with diagnoses including atrial fibrillation, unspecified dementia without behavioral disturbances, and alcohol abuse. A review of orders revealed an order for SEROquel Tablet 25 milligrams (mg). Give 25 mg by mouth at bedtime related to Unspecified .Dementia without Behavioral Disturbances. Start date: 01/04/22. Review of the electronic Medication Adminsitration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the months of May, June, and July of 2022 did not include any behavior or side effects monitoring for psychotropic medications. [...]
April 8, 2021Standard inspection · 2 citations
- D
Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interviews, the facility failed to post the total number, and the actual hours worked of the direct care staff for the benefit of the facility residents and the public on 04/05/21 through 04/07/21 as evidenced by the position and location of the clipboard that was identified by the Staffing Coordinator as the posting location.
- 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 observations, interviews and record review the facility did not ensure that Controlled substances were locked and stored in a permanently affixed compartment in two of two medication storage rooms sampled.
Fire safety inspections
5 fire safety citations on file: 3 on July 28, 2022, 2 on April 8, 2021.
Every fire safety citation5 citations
- 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 · July 28, 2022 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 28, 2022 · 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 · July 28, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 8, 2021 · 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 · April 8, 2021 · Corrected (the home has a date of correction)