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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
2K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
31D
6E
2F
Potential for minimal harm
0A
0B
0C
September 18, 2024Complaint inspection · 3 citations
- G
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteCross Reference F623 and F626 Based on interview and record review, the facility failed to document in the medical record the reasons why they could not meet the needs and readmit one (#1) of two residents reviewed for transfer and discharge rights.
- G
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteCross Reference F622 and F623 Based on interview and record review, the facility failed to permit readmission from the hospital for one (#1) of two residents reviewed for transfer and discharge rights.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteCross Reference F622 and F626 Based on interview and record review, the facility failed to provide a written transfer and discharge notice to the resident representative, and a copy to the Office of the State Long-Term Care (LTC) Ombudsman for one (#1) of two residents reviewed for transfer and discharge rights.
August 29, 2024Standard inspection, Complaint inspection · 17 citations
- G
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to prevent multiple significant medication errors for 1 resident (#347) out of 4 residents reviewed. Resident #347 was admitted to the facility on [DATE] for intravenous antibiotic administration due to intracranial abscesses and with diagnosis of opioid abuse with withdrawals. She was transferred to the facility with orders to treat the opioid abuse with withdrawals with buprenorphine and naloxone 8-2 mg (Suboxone) sublingually three times a day. The facility failed to provide Resident #347's her Suboxone medication for two and a half days. Resident #347 arrived at the facility with hospital orders to take buprenorphine and naloxone (Suboxone) 8-2mg sublingually film three times a day. The medication was ordered as buprenorphine 2mg sublingually twice day. [...]
- G
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented action plans to correct deficient practices identified during an intervening complaint survey conducted on 9/18/24 and the recertification survey originally conducted on 8/26/24 to 8/29/24 as evidenced by: [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to 1. Maintain an infection prevention and surveillance program for 6 out of 6 months reviewed. 2. The facility also failed to ensure their infection control guidelines policy was reviewed yearly and was revised with current evidence-based practices. 3. The facility also failed to ensure hand hygiene was performed during lunch meal service for one out of three meal observations. 4. The facility also failed to ensure enhanced barrier precautions were in place for two residents with intravenous lines (#347 and #31) out of two residents sampled for intravenous lines.
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review the facility failed to have a qualified infection Preventionist who was qualified by education, training, experience or certification for one of one staff member acting as the infection Preventionist.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure a clean, sanitary homelike environment for two out of two units in the facility.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interviews, the facility failed to ensure the Level I Pre-admission Screening and Resident Review (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses were accurate for nine residents (#25, #27, #24, #26, #7, #4, #35, #28, #39) out of 20 residents sampled. 1. Review of Resident #4's admission Record showed Resident #4 was originally admitted on [DATE] with a readmission date of 06/18/2024 after returning to the facility from a hospitalization. Resident #4's admission Record showed he was admitted to the facility with diagnoses to include Psychoactive Substance Dependence and Alcohol Dependence. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on observation, record review and interviews the facility failed to ensure Minimum Data Set (MDS) Assessments were completed in a timely manner for two (#20 and #33) residents out of 20 sampled residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interviews the facility failed to ensure the accuracy of the Resident Assessment Minimum Data Set (MDS) for two residents (#10, #9) of 20 residents reviewed.
- 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 develop and/or implement an effective care plan for two (#35 and #24) residents out of 20 sampled residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure one resident (#7) out of one sampled residents received assistance to maintain good grooming and personal hygiene.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interview, and record review 1. The facility failed to provide oxygen according to physician's orders for one resident (#7) out of 2 sampled residents, and 2. the facility failed to ensure flammable products (petroleum jelly) were not used during oxygen use for one resident (#25) out of 2 sampled residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and twelve errors were identified for two residents (#35, #25) out of three residents observed. These errors constituted a 48.00% medication error rate.
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure bed rails were secure for 1 resident (#9) of 5 sampled.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure call lights were functioning properly in resident rooms and bathrooms for one resident (# 24) out of six residents sampled
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program to prevent flying insects in resident rooms and resident common areas for four of four days.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review the facility failed to assess with an Interdisciplinary Team approach, obtain physician orders and develop a Comprehensive Person-Centered Care Plan for two of two sampled residents (#50 and #51) related to administering their own medications.
- 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 observations, record review, and interviews, the facility failed to ensure medications were stored in a secure and safe manner for one resident (Resident #2) of one resident allowed to self-administer medications, and leaving medication unattended on one (North) of two medication carts .
November 2, 2023Complaint inspection · 7 citations
- K
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a safe and effective discharge planning process for three (#8, #3, and #1) of five residents sampled for discharge. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for dialysis or home health services. Resident #3 had severe cognitive impairment and was discharged in a taxi cab to live with a family member who was not present or prepared to care for the resident in the home. Resident #3 had no way to access the home upon his arrival and the taxi cab driver contacted law enforcement for assistance. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. [...]
- K
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to advocate and provide medically related social services to ensure three (#8, #3, and #1) of five residents sampled for discharge had the community supports, services, and equipment to ensure a safe discharge to a safe and habitable location. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for the continuation of life-saving dialysis treatment, home health services, or community support to ensure food availability and food preparation for special dietary needs. Resident #3, who suffered from severe cognitive impairment, was placed in a taxi cab by himself and sent home to live with family who was not present or prepared to care for the resident. Resident #3 had an invalid order for home health services and no way to access the home upon his arrival. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record review the facility failed to monitor one diabetic resident (#5) out of three residents sampled for blood glucose levels as ordered.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pain management for one resident (#6) of three residents sampled.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on a interviews and record reviews the facility failed to ensure a Registered Nurse (RN) was available for 8 consecutive hours every day, seven days a week, for a two-week period from 10/01/23 to 10/14/23.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to 1) establish a system of receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation; and 2) determine that drug records are in order and an account of all controlled drugs is maintained and periodically reconciled for two residents (#4 and #6) of three residents sampled.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review the facility failed to ensure the medical record had complete and accurate documentation related to meals and wounds for two residents (#2 and #5) out of nine residents sampled.
September 8, 2022Standard inspection · 6 citations
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interviews and record review the facility failed to ensure implementation of an effective performance improvement action plan ongoing for 15 months related to care plans. Failures included not ensuring consistent audit process and not analyzing and tracking data from audits that were conducted to implement correction. This resulted in five residents (#144, #147, #39, #145, and #146) out of five residents sampled not having comprehensive care plans developed by the interdisciplinary team and within required timeframes.
- 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 record review and interviews the facility failed to ensure code status (type of emergent treatment a person would or would not want to receive if their heart or breathing were to stop) was identified and confirmed upon admission for two residents (#146, #144) out of four sampled residents.
- 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 record review and interviews the facility failed to ensure baseline care plans with the instructions needed to provide effective and person-centered care according to professional standards of quality care were developed for two newly admitted residents (#147 and #144) out of four sampled residents.
- 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 observations, interview, facility policy and record review the facility failed to ensure a resident centered care plan was developed and implemented related to behavior monitoring for use of a psychotropic medication for one (Resident #39) of five residents sampled.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and interviews the facility failed to ensure comprehensive care plans were developed by the interdisciplinary team within required timeframes for two newly admitted residents (#145, #146) out of four residents sampled.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review, and interview, the facility failed to monitor behaviors related to a psychotropic drug regime for one resident (#39) of five sampled residents.
March 18, 2021Standard inspection · 12 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interviews, observations and record reviews, the facility did not ensure that 1) medications were available for 2 residents, (Resident #3 and Resident #17), and 2) did not ensure eye drops orders were clarified for 1 resident, (Resident # 2) of 21 sampled residents.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and twenty-four errors were identified for four (#16, #7, #19, and #13) of five residents observed. These errors constituted a 64.86% medication error rate.
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on record review and interview the facility failed to designate a healthcare professional with specialized training as the Infection Control Preventionist (ICP) for the facility.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, staff interviews, and record review the facility failed to ensure that one (#20) of 21 sampled residents was provided with linens to cover a mattress.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interviews, policies and resident council minutes review, the facility failed to act upon resident's concerns and grievances as evidenced by: (1) same grievances reported and documented without resolution for 6 out of 6 resident council meeting minutes. (2) Facility not having social services personnel available. (3) Nursing home administrator (NHA) failure to attend resident council meetings per the request of council participants. (4) NHA failure to respond to grievances and complaints.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure it developed skin assessments for two residents (#5, and #45) of 21 sampled residents.
- 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 observations, record reviews, and interviews the facility failed to develop and implement a baseline care plan for one (#99) of 21 residents sampled.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility did not ensure that the resident and resident representative were involved in care planning for one (Resident #3) of nine residents reviewed for care planning.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure three (#3, #14, #20) of four residents reviewed for Activities of Daily Living (ADL) received assistance with showers and nail care.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on interviews, observations, and records review, the facility failed to provide an on-going activities program to support the comprehensive assessment and care planned choices and preferences for one (#3) of three residents sampled for activities.
- 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, interviews and record review, the facility failed to maintain the reach in freezer at appropriate temperatures and ensure staff kept personal items separate from food storage on 2 of 2 days observed (3/15 and 3/17/21).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview the facility failed to ensure one (#18) of 21 sampled residents had an accurately documented code status in the medical record.
Fire safety inspections
19 fire safety citations on file: 8 on August 29, 2024, 2 on September 8, 2022, 9 on March 18, 2021.
Every fire safety citation19 citations
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · August 29, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 29, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · September 8, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · September 8, 2022 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 18, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 18, 2021 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 18, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 18, 2021 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 18, 2021 · 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 18, 2021 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 18, 2021 · 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 18, 2021 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · March 18, 2021 · Corrected (the home has a date of correction)