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
12D
1E
4F
Potential for minimal harm
0A
0B
0C
November 21, 2024Standard inspection · 15 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that clinical nutritional assessments were completed within the scope of practice and failed to ensure appropriate competencies in accordance with standards of practice for 5 of 6 residents reviewed for nutrition (Residents #55, #6, #14, #43, and #26). This had the potential to affect 67 residents on the facility's current census.
- 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, interview, and record review it was determined that the facility failed to store prepare, distribute, and serve food in accordance with professional standards for food service safety in the skilled nursing home kitchen, satellite serving kitchen, and the main campus kitchen, which potentially effected all of the 66 facility residents.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to dispose of garbage and refuse properly.
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interviews and record review, the Administrator failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The facility's Administrator failed to ensure that the Consultant Clinical Dietitian provided dietary services, supervision, and oversight in accordance with State and Federal Guidelines. The facility's Administrator failed to ensure that the current Certified Dietary Manager (CDM) was providing dietary services within her scope of practice for 6 of 6 residents reviewed for nutrition (Residents #17, #43, #14, #55, #6, and #26). This had the potential to affect 67 residents who were on the census at the facility.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation and interview, the facility failed to maintain resident privacy by posting signs with private medical information on the entrance doors to their rooms. This affected 12 residents in the final sample (Residents #4, #9, #14, #16, #17, #22, #26, #38, #43, #53, #55, and #211) with the potential to affect 27 additional residents in the facility with signs on their doors.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews and record review the facility failed to treat each resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her life, recognizing each resident's individuality for 2 of 21 sampled residents (Residents #26 and #18)
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided (Administration of Intravenous [IV] medication) meet professional standard of quality for 1 of 12 Licensed Practical Nurses (LPNs) employed by the facility for 1 of 1 resident with Peripherally Inserted Central Catheter affecting Resident #264.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to assess and provide adaptive eating utensils and drinking cups to maintain independence in eating ability for 1 (Resident #43) of six residents reviewed for nutrition.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to ensure nutritional assessments were completed accurately with appropriate interventions in place for 3 of 6 residents reviewed for nutrition (Residents #55, #6 and #26).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility failed to transcribe the physician's order agreeing to pharmacy recommendation for psychotropic medication for 1 of 5 sampled residents for unnecessary medication affecting Resident #22.
- 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 observations, interviews, and record review, the facility failed to ensure that PRN (as needed) orders for psychotropic drugs are limited to 14 days for 2 of 5 sampled residents for unnecessary medication (Residents #22 and #53).
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure that the correct fluid restriction was provided as per physician's order for 1 of 1 resident reviewed for Dialysis (Resident #55).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain medical records for each resident that are complete and accurately documented for 1 of 1 resident sampled for transmission based precautions with peripherally inserted central catheter (PICC) affecting Resident #264.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate infection prevention and control practices during medication administration for 1 of 5 residents observed for medication administration affecting Resident #265.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, and interview it was determined that 6 of 13 resident room bathrooms located on the East Wing of the second floor were disabled, inoperable, and out of reach in a resident emergency. The six identified rooms were noted to effect Resident's #2, #7, #17, #24, #31, and #41.
March 2, 2023Standard inspection · 2 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, staff and resident interview, the facility failed to provide the necessary services to maintain personal grooming and hygiene for 1 (Resident #13) of 2 sampled residents requiring assistance with activities of daily living.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, record review, review of the facility's protocol, Resident and staff interviews, the facility failed to implement preventive measures to prevent the development of pressure ulcers for 1 (Resident #13) of 1 resident at risk for pressure ulcer.
July 29, 2021Standard inspection · 0 citations
Fire safety inspections
6 fire safety citations on file: 5 on March 2, 2023, 1 on July 29, 2021.
Every fire safety citation6 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 2, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 2, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 2, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 2, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · March 2, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 29, 2021 · Corrected (the home has a date of correction)