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
0E
1F
Potential for minimal harm
0A
0B
1C
December 9, 2021Standard inspection · 0 citations
April 11, 2019Standard inspection · 2 citations
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview, a review of residents council meeting minutes and a review of a facility policy titled, POLICY: Grievances/Concerns, the facility failed to act promptly to resolve the resident council members grievances regarding dirty meal trays left in the dining room overnight. This deficient practice affected 2 of 2 residents who had voiced concerns in resident group meetings of the trays being left in the dining room overnight.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, interview and the facility's Nursing Staff Directly Responsible for Resident Care form, the facility failed to ensure the nurse staffing data was posted on the evening shift on 4/10/19. This was observed on one of three days of the survey. The facility further failed to consistently include the actual total hours worked by nursing staff each shift. This deficient practice was observed on three of three days of the survey and had the potential to affect 71 of 71 residents in the facility.
March 15, 2018Standard inspection · 3 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 observations, interviews, and review of facility policies titled, Monitoring of Milk Temperature, Labeling food for Freezer, Cleaning of Ice Machine, Ice Chest and Scoops and a facility document titled, Temperature Log for Serving Line, the facility failed to ensure: 1) the temperature of the milk was taken before leaving the kitchen; 2) hamburger meats in the freezer were labeled; 3) the ice machine was free of a black substance on the inside; and 4) residents' serving trays were not on the table. This had the potential to affect 71 of 77 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Monitoring of Milk Temperature with a copyright date of 2017 revealed: Policy: It is the policy of this facility to maintain temperatures of milk at a temperature of 41 degrees or below . 1. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and review of a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure an allegation of abuse was reported within the two hour time frame. This was noted on one of two Facility Reported Incidents reviewed during the survey. Findings Include: A review of the facility's Policy & Procedure titled Abuse, Neglect and Exploitation with a Reviewed/Revised date of 12/28/16, revealed, Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Policy Explanation and Compliance Guidelines: . 4. [...]
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations and interviews the facility failed to ensure window seals were not found with blankets and towels folded in them to prevent draftiness in resident rooms. This affected RL (Room Locators) 1 through 5, five of fifty-six rooms that were observed. Findings Include: An observation was made on 3/14/18 at 7:43 a.m., of RL #3. It was noted there was one or more pieces of cloth rolled up on the ledge of the window. An observation was made on 3/14/18 at 3:32 p.m., of RL #5 with a rolled up piece of cloth in the window seal. An observation was made on 3/14/18 at 3:33 pm., of RL #3. The cloth remained rolled up in the window seal. Observations noted during a tour of the facility on 3/5/18 were as follows: 11:00 a.m. RL #1, towels were in the window. 11:10 a.m. RL #2, a blanket was in the window. 11:15 a.m. RL #3, a blanket was in the window. 11:15 a.m. [...]
Fire safety inspections
12 fire safety citations on file: 5 on December 9, 2021, 3 on April 11, 2019, 4 on March 15, 2018.
Every fire safety citation12 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 9, 2021 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 9, 2021 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · December 9, 2021 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · December 9, 2021 · Past noncompliance: already fixed when inspectors found it
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · December 9, 2021 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 11, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 11, 2019 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 11, 2019 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · March 15, 2018 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 15, 2018 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 15, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 15, 2018 · Corrected (the home has a date of correction)