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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
1F
Potential for minimal harm
0A
0B
0C
April 9, 2022Standard inspection · 0 citations
June 13, 2019Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, the facility failed to ensure: 1) a licensed nurse did not place Resident Identifier (RI) #53's medication on the over bed table, then into her pocket, prior to placing the medication back into the medication cart; and 2) a licensed nurse washed her hands prior to preparing RI #31's medications. These failures affected RI #s 31 and 53, two of five residents, and two of four nurses, observed during medication administration observations. Findings Include: 1) On 6/12/19 at 4:34 p.m., during medication administration observations, Employee Identifier (EI) #3, a Licensed Practical Nurse, removed medication (eye drops) from the medication cart, placed the medication on RI #53's overbed table, then stored the medication in her pocket while administering other medications. [...]
June 7, 2018Standard 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 observation, interviews, and review of the facility policy titled . SUBJECT: Food and Supply Storage Procedures and review of the 2017 Food Code, the facility failed to ensure: 1.) a dented can of pineapple chunks was removed from stock rotation; 2.) Glucerna TF was not stored past the manufacturer's use by date; and 3.) raw chicken was not stored directly over coed/prepared pork tenderloins. These failures had the potential to affect all 60 residents receiving meals from the dietary department.
- E
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 wroteThe facility failed to ensure Resident Identifier (RI) #12 was assessed to determine the need for side rails and the risk of entrapment prior to utilizing two upper side rails. Further the facility failed to obtain informed consent prior to applying side rails for RI #12. This affected RI #12 one of one resident sampled for siderail use but had the potential to affect 28 of 64 total residents in the facility identified by staff as using side rails.
- 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 observation, record review and interviews, the facility failed to ensure an individualized care plan was developed to address Resident Identifier (RI) #12's use of side rails. This affected one of 16 sampled residents for whom care plans were reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews and review of a facility policy titled, Gloving, the facility failed to ensure a licensed staff member wore gloves when administering a subcutaneous injection to Resident Identifier (RI) #7 on 6/06/2018. This affected one of three residents observed for subcutaneous injections during medication administration observations.
Fire safety inspections
9 fire safety citations on file: 3 on April 9, 2022, 4 on June 13, 2019, 2 on June 7, 2018.
Every fire safety citation9 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · April 9, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 9, 2022 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 9, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 13, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 13, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · June 13, 2019 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 13, 2019 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 7, 2018 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 7, 2018 · Corrected (the home has a date of correction)