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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
1F
Potential for minimal harm
0A
0B
1C
January 7, 2022Standard inspection · 2 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and review of facility policies titled Respiratory Program Policy and Procedure and N95 Respirator Mask, the facility failed to ensure staff properly wore source control throughout the facility. Specifically, facility staff were observed wearing N95 respirators (masks) with the mask straps cut and tied to be worn behind the ears instead of around the head; N95 mask straps were observed hanging loosely instead of around the head; and N95 masks were observed not covering the nose and mouth. This had the potential to affect all residents and occurred during the COVID-19 pandemic.
- 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 record review, interview, and review of facility policies titled Depression - Clinical Protocol, Behavioral Assessment, Intervention, and Monitoring and Antipsychotic Medication Use, the facility failed to ensure Resident Identifier (RI) #51, who received antipsychotic and antidepressant medications, was monitored for behaviors and/or side effects of precribed medications. This affected RI #51, one of four sampled residents receiving an antipsychotic medication and one of two sampled residents receiving an antidepressant medication.
May 2, 2019Standard inspection · 2 citations
- 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 a facility policy titled Baseline Care Plan, the facility failed to ensure: 1) Resident Identifier (RI) #143's resident representative received a copy of RI #143's Baseline Careplan Summary within 48 hours when the resident was admitted to the facility on [DATE]; and 2) a baseline care plan was completed for RI #145 when the resident was admitted to the facility on [DATE]. These deficient practices affected RI #s 143 and 145, two of 22 sampled residents whose plans of care were reviewed. Findings Include: Review of an undated facility policy titled Baseline Care Plan, revealed the following: . Policy Explanation and Compliance Guidelines: . 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interview, record review and review of a facility policy titled Infection Prevention and Control Program, the facility failed to ensure Resident Identifier (RI) #52 had an isolation sign posted on his/her door to alert staff, family members, and/or visitors of isolation precautions. This deficient practice affected RI #52, one of two residents sampled for isolation precautions, and was observed on three of three days of the survey. Findings Include: Review of an undated facility policy titled Infection Prevention and Control Program, revealed the following: Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. [...]
April 12, 2018Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews, a review of CMS' (Centers for Medicare and Medicaid)Long-Term Care Facility Resident Assessment Instrument Manual (RAI), and record reviews, the facility failed to ensure a Quarterly MDS (Minimum Data Set)was coded accurately for transfer assistance required by staff for RI (Resident Identifier) #32. This affected RI #32, one of twenty residents sampled for MDS review. Findings Include: A review of CMS' Long-Term Care Facility Resident Assessment Instrument Manual, Version 3.0, dated October 2017, revealed: DEFINITION ADL (Activities of Daily Living) SUPPORT PROVIDED Measures the most support provided by staff over the last 7 days, even if that level of support only occurred once. Steps for Assessment 1. Review the documentation in the medical record for the 7-day look-back period. 2. [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, interviews, and a facility policy titled, Nurse Staffing and Posting Information, the facility failed to ensure that staffing posting included the actual number of licensed staff working on each shift. This was observed on three of four days of the survey and had the potential to affect all residents in the facility. Findings Include: A review of an undated policy titled, Nurse Staffing Posting Information, revealed, Policy: It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will contain the following information: a. Facility name b. The current date c. Facility's current census d. [...]
Fire safety inspections
19 fire safety citations on file: 8 on January 7, 2022, 4 on May 2, 2019, 7 on April 12, 2018.
Every fire safety citation19 citations
- F
Use approved construction type or materials.
K 161 · January 7, 2022 · Waiver
- E
Have an enclosure around a vertical opening shaft.
K 311 · January 7, 2022 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · January 7, 2022 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · January 7, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · January 7, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 7, 2022 · Corrected (the home has a date of correction)
- D
Have properly sized and located compartments to protect residents from smoke.
K 371 · January 7, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 7, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 2, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 2, 2019 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · May 2, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 2, 2019 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 12, 2018 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 12, 2018 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · April 12, 2018 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 12, 2018 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 12, 2018 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 12, 2018 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · April 12, 2018 · Corrected (the home has a date of correction)