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 2 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
0E
0F
Potential for minimal harm
0A
0B
0C
December 10, 2020Standard inspection · 0 citations
March 12, 2020Standard inspection · 1 citation
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, medical record reviews, and review of the facility policy titled Administering Medications, the facility failed to ensure the medications error rate was less than five percent. During medication administration observations from 3/11/20 through 3/12/20 two errors were observed out of twenty-five total opportunities, equaling a medication error rate of eight percent. This affected Resident Identifier (RI) #4 and RI #59, two of three residents observed for medication pass. Findings Include: A facility policy titled Administering Medications, revised December 2012, revealed: Policy Statement Medications shall be administered . as prescribed. 3. Medications must be administered in accordance with the orders . 7. The individual administering the medication must . verify the . right medication .before giving the medication. [...]
March 14, 2019Standard inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, review of medical records, review of Certified Nursing Assistant job description and review of a facility training document, the facility failed to ensure staff provided Activities of Daily (ADLs) assistance to ensure facial hair was removed for Resident Identifier (RI) #s 11 and 22. This affected RI #s 11 and 22, two of five residents sampled for ADLs. Findings Include: A review of an undated Certified Nursing Assistant job description revealed, . Purpose of Your Job Position The primary purpose of you job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Job Functions . Duties and Responsibilities . Personal Nursing Care Functions . Keep hair on female residents clean shaven (i.e., facial hair, under arms, on legs, etc.) . [...]
Fire safety inspections
8 fire safety citations on file: 2 on December 10, 2020, 3 on March 12, 2020, 3 on March 14, 2019.
Every fire safety citation8 citations
- D
Install an approved automatic sprinkler system.
K 351 · December 10, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 10, 2020 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 12, 2020 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 12, 2020 · 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 · March 12, 2020 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 14, 2019 · Corrected (the home has a date of correction)
- D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · March 14, 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 · March 14, 2019 · Corrected (the home has a date of correction)