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 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
0E
0F
Potential for minimal harm
0A
0B
0C
June 11, 2024Complaint inspection · 3 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 6 sampled residents resulting in a transfer to a higher level of care (Resident #1).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were 3 medication errors in 34 opportunities for a medication error rate of 8.82%. These medication errors affected Resident #3 and #4.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment and help prevent the development and transmission of communicable disease or infections on 1 of 2 resident care units (200 Hall).
March 21, 2024Standard inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to accurately complete a discharge Minimum Data Set (MDS) assessment for 1 of 5 closed record reviews, Resident #80.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan for one of 18 residents in the survey sample, resident # 56.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents requiring dialysis services receive care consistent with the comprehensive person-centered care plan for 1 of 18 current residents in the survey sample, Resident #9.
January 10, 2024Complaint inspection · 5 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan for 2 of 15 residents in the survey sample, Residents #13 and #11.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide necessary pressure ulcer treatment consistent with medical provider orders to promote healing for 2 of 15 residents in the survey sample, Resident #8 and #10.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents are free of significant medication errors, for 1 of 11 current residents in the survey sample, Resident #9.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 15 residents in the survey sample, Resident #12.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections on one of two resident care units, Hall 200.
July 27, 2022Standard inspection · 13 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the correct code status for 1 of 19 residents in the survey sample, Resident #39. For Resident #39, the facility staff failed to carry out the resident's and family's decision to change their code status to do not resuscitate (DNR).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to follow physician's orders for 2 of 19 residents, Resident #59 and Resident #68. For Resident #59 the facility staff failed to notify the physician when the resident's blood sugars were outside of the ordered parameters. For Resident #68 the facility staff failed to administer the medication, Keflex as ordered by the physician.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing for 1 of 19 residents in the survey sample, Resident #39. For Resident #39, the facility staff failed to follow the wound care physician's treatment plan for pressure areas to the left and right buttocks.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to ensure water temperatures were maintained in acceptable parameters to decrease the risk of resident injury.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide oxygen therapy according to the physician's order and the comprehensive person-centered care plan for 1 of 19 residents in the survey sample, Resident #53. For Resident #53, the facility staff failed follow the physician's order for oxygen administration.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to inspect the bed frame, mattress, and the bed rails for the risk of entrapment prior to resident use and failed to assess for the safe use of side rails and risk of entrapment following an incidence of entrapment for 1 of 19 residents in the survey sample, Resident #372. For Resident #372, the facility staff failed to assess the resident for the safe use of side rails and risk of entrapment following an incident where the resident's neck became stuck between the bed and bed rail. Facility staff was unable to provide evidence of a bed safety inspection for Resident #372's bed prior to the incident.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, facility document review, and clinical record review the facility staff failed to ensure medications were available for administration for 1 of 19 residents, Resident #59. For Resident #59 the facility staff failed to ensure the medication Neurontin was available for administration for 5 consecutive doses. Neurontin (gabapentin) is a medication used in the treatment of neuropathy and seizures.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to act upon drug regimen review recommendations for 1 of 19 residents in the survey sample, Resident #53. For Resident #53, the facility staff failed to carry out a physician approved, drug regimen review recommendation for Alprazolam, a benzodiazepine used to treat anxiety and panic disorders.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interviews, clinical record reviews, and facility document reviews, the facility staff failed to ensure 1 of 19 residents, Resident #6, was free of significant medication errors. Resident #6 did not receive their insulin per provider orders.
- 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 observation, staff interview, facility document review and in the course of a complaint investigation the facility staff failed to properly store and/or label medications. For medication cart A, the facility staff failed to discard expired medication, failed to ensure an insulin pen had a label, failed to ensure medication label contained an expiration date, and failed to place an opened on/use by date on 13 opened insulin pens. For medication cart B, the facility staff failed to dispose of expired medications.
- D
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, the facility staff failed to ensure food was prepared and stored under safe and sanitary conditions in the kitchen and 2 of 2 nourishment rooms. A dietary aide was observed working in the kitchen without a hair restraint, the refrigerators in each nourishment room contained unlabeled and undated items, the 400 Hall nourishment room contained outdated juice, and the 400 Hall ice chest contained an insect within the ice.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 1 of 19 residents, Resident #59. For Resident #59 the facility staff failed to record the resident's blood sugar and failed to document medications as administered on the medication administration record.
- 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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 19 residents in the survey sample, Resident #372. For Resident #372, the facility staff failed to follow a physician's order for contact precautions following a report of bed bugs in the resident's room.
December 5, 2019Standard inspection · 0 citations
Fire safety inspections
21 fire safety citations on file: 6 on March 21, 2024, 11 on July 27, 2022, 4 on December 5, 2019.
Every fire safety citation21 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 21, 2024 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 21, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 21, 2024 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 21, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 21, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · July 27, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 27, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 27, 2022 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · July 27, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · July 27, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · July 27, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · July 27, 2022 · Waiver
- E
Have properly located and lighted "Exit" signs.
K 293 · July 27, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 27, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 27, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 27, 2022 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 5, 2019 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · December 5, 2019 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · December 5, 2019 · Corrected (the home has a date of correction)