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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
3E
7F
Potential for minimal harm
0A
0B
0C
October 2, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews, resident record review, review of the facility investigative file, review of a Facility Reported Incident (FRI), and review of a facility policy titled Abuse, Neglect and Exploitation, the facility failed to conduct a thorough investigation of an allegation of physical abuse on 09/13/2024 to include determining the time the alleged incident occurred. This citation resulted from the investigation of complaint/report number AL00048805 and had the potential to affect Resident Identifier (RI) #1, one of six residents sampled for abuse.
August 13, 2024Complaint inspection · 2 citations
- F
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record reviews, interview, facility's policies titled Notification of Changes, and Information and Communication the facility failed to ensure residents' families were notified when the facility was unable to maintain the first floor's residents' right to a safe and homelike environment when the facility's air conditioning system failed to maintain temperatures less than 81 °F (degrees Fahrenheit) in the residents' common areas and residents' rooms on the first floor. Due to the elevated temperatures, the facility initiated an enhanced hydration round program. The facility did not notify residents' families or representatives of the elevated temperatures or the enhanced hydration round program. This deficient practice had the potential to affect all 98 residents residing on the first floor of the facility. [...]
- F
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, interviews, record reviews, and the facility policy titled, Safe and Homelike Environment, the facility failed to maintain safe and comfortable temperatures in residents' common areas and residents' rooms on the first floor. The facility failed to ensure temperatures in residents' common areas and residents' rooms were not above 81 degrees from 08/09/2024 through 08/13/2024. The temperatures on the first floor were recorded above 81 °F (degrees Fahrenheit) during all five days of the survey. This deficient practice had the potential to affect all 98 residents residing on the first floor of the facility. The deficiency was cited as a result of the investigation of complaint/report number AL00047537 and AL00047538. Findings Include: On 08/07/2024, the State Survey Agency received an anonymous complaint alleging the facility had no air conditioning. [...]
March 29, 2024Standard inspection, Complaint inspection · 9 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, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and a facility's policy titled Sanitation Inspection, the facility failed to ensure the stove top, knobs, handles, and drip pans were free of a heavy grease build up. This had the potential to affect 129 of 130 residents who received meals from the facility's kitchen. Findings Include: A review of 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, documented: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . A review of policy titled Sanitation Inspection dated 12/23 documented: .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary .1. All food service areas shall be kept clean, sanitary . [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and facility policies titled Hand Hygiene, Standard Precautions Infection Control, Handling Clean Linen, and Water Management Program the facility failed to ensure: 1) Laundry Staff (LS) #7 washed her hands after leaving Resident Identifier (RI) #54 and RI #10's room with contaminated laundry hangers and touching clean clothing for RI #74. 2) LS #9 kept clean sheets off the floor and off her clothing while folding clean laundry on 03/28/24. 3) Clean blankets for the residents were stored in a clean dust free area and ensured the blankets were not touching the wall. 4) Certified Nursing Assistant (CNA) #10 washed or sanitized her hands after leaving RI #115's room and before picking up RI #23's meal tray while delivering meals on 3/28/24. [...]
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interviews, record review, and facility's policy titled Infection Prevention and Control Program the facility failed to ensure the facility employed a certified infection preventionist from 1/5/2022 until 3/29/2024. This deficient practice affected 130 residents in the facility. Findings Include: A review of a facility policy titled Infection Prevention and Control Program with an implemented date of 12/22, and a reviewed date of 12/2023 revealed: . Policy Explanation and Compliance Guidelines. 1. The designated Infection Preventionist is responsible for oversight of the program and serves a consultant to our staff on infectious diseases. A review of the facility's employment record for the previous certified infection preventionist revealed a hire date of 03/27/2020 and last day of employment as 01/05/2022. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observations, interviews, and a review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure 1) Two ovens in the kitchen had exposed electrical wiring and were in working condition 2) The walk-in freezer was free from excessive ice buildup on two fans, the floor, ceiling, and boxes containing food products. This was observed on the initial tour of the kitchen on 03/26/2024. This had the potential to affect 129 of 130 residents receiving meals from the facility kitchen. Findings Include: The 2022 U.S. Food and Drug Administration documents the following: . Maintenance and Operation 4-501.11 Good Repair and Proper Adjustment A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements . [...]
- 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 observations, interviews, review of a facility policy titled Safe and Homelike Environment, the facility document titled Plan of correction for torn floors and complaint/report number AL00046076, the facility failed to ensure Resident Identifier (RI) #128's room's floor covering was not torn, ceiling tiles were not stained in RI #128's room, and that RI #128's room did not have a urine odor. This affected RI #128. The torn floors had the potential to affect residents in 47 rooms. Findings Include: Review of a facility policy Safe and Homelike Environment with a revised date of 12/2023 documented Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, . [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews, resident record reviews, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, the facility failed to ensure Section N, Medications, of Resident Identifier (RI) #124's quarterly Minimum Data Set (MDS) was accurately coded for anticoagulant and antiplatelet medication. This deficient practice affected RI #124 one of twenty-six sampled residents whose MDS was reviewed during the survey. Findings Include: The Centers for Medicare &Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 Section N documented: . N0415: High-Risk Drug Classes: Use and Indication .E. Anticoagulant ( . warfarin, heparin, or low-molecular weight heparin) . Do not code antiplatelet medications such as aspirin . [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, interview and review of the facility policy Resident Assessment - Coordination with PASARR Program, the facility failed to submit for a new Level I for Resident Identifier (RI) #14 when a new diagnosis for Psychotic Disorder was given on 07/07/2021. This affected RI #14 one of two residents reviewed for PASARR (Pre-admission Screening Annual Resident Review). Findings Include: Review of a facility policy Resident Assessment - Coordination with PASARR Program with a revised date of 12/2023 documented . Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions . a. PASARR Level I i. Negative Level I Screening - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder arises later. 9. [...]
- 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 interview ,record review and a facility policies titled Comprehensive Care Plans and Oxygen Administration, the facility failed to ensure a care plan was developed for Resident Identifier (RI) #13's use of oxygen therapy. This affected RI #13, one of 26 sampled residents whose plans of care were reviewed. Findings Include: A facility policy titled Comprehensive Care Plans revised 01/2023 indicated: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 8. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review and interview the facility failed to ensure Resident Identifier (RI) #483 had a physician's order for a urinary catheter when he/she was admitted to the facility with a Catheter on 08/20/2022. This affected one of three residents sampled for urinary catheter use. Findings Include: RI #483 was admitted to the facility on [DATE]. A review of RI #483's Physician Orders for August 2022 revealed no order for the use of a catheter. A review of RI #483's progress notes from 08/28/2022 documented that RI #483's catheter was removed. A telephone interview with the Medical Director revealed that he gave a verbal order to remove the catheter on 08/28/2022. On 03/28/2024 at 10:54 AM an interview was conducted with the Admissions Nurse (AN). The AN stated that RI #483 was admitted to the facility on [DATE] with a foley catheter. [...]
November 20, 2019Standard 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 observation, interview, and review of the facility's policy titled Three Compartment Sink Sanitization, the facility failed to ensure a kitchen aide did not sanitize a knife in the three compartment sink containing food particles in the sanitizing compartment. Further, the kitchen aide removed the knife from the sink using bare hands and placed it on the wall with other clean knives for future use. This had the potential to affect 122 residents receiving meals from the facility's kitchen.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure Resident Identifier (RI) #14 was provided privacy during medication administration by a licensed nurse. This affected RI #14, one of three residents observed during medication administration, and one of three licensed nurses observed during medication administration. Findings Include: RI #14 was admitted to the facility on [DATE] with diagnoses to include Dry Eye Syndrome of Bilateral Lacrimal Glands. On 11/19/19 at 08:22 a.m., Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed during a medication administration for RI #14. After EI #3 entered RI #14's room, she left the door and privacy curtain open for public view, and visible for RI #14's roommate. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and review of a facility policy titled Infection Control- Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), washed her hands after she placed a topical medication patch to Resident Identifier (RI) #120's right upper back, removed her gloves, and prior to placing RI #120's nasal medication in the medication cart drawer. This affected RI #120, one of three residents observed during the medication administration pass, and EI #1, one of three nurses observed during medication pass. Findings Include: A review of a facility policy titled, Infection Control - Hand Hygiene, dated 11/17/2017, revealed . It is the policy of the facility to perform hand hygiene with national standards . PROCEDURE: . 2.hand hygiene is to be performed: . d. [...]
November 8, 2018Standard inspection · 7 citations
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interviews, record reviews and a review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual and review of CMS (Centers for Medicare and Medicaid Services) Submission Report MDS (Minimum Data Set) 3.0 NH (Nursing Home) Final Validation, the facility failed to ensure Resident Identifier (RI) #s 14, 16, 76, 9, 15, 13, 19, 1, 6, 8, 12, 10, 11, 7, 5, and 17 MDS assessments were transmitted in a timely manner. This affected 16 of 26 sampled residents for whom MDS assessments were reviewed. Findings Include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, Chapter 5: Submission and Correction of the MDS Assessments, page 5-3, revealed the following: . Transmitting Data: . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date . [...]
- E
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, interview, and review of a facility policies titled, Pharmacy Services and Stability of Medications After Opened, the facility failed to ensure expired medications were not stored on medication carts and in the medication storage room. This deficient practice affected three of the four medication carts and one of two medication rooms viewed for expired medications. Findings Include: Review of a facility policy titled, Pharmacy Services, revised 11/17/17, revealed the following: . 14. Expired/discontinued medication that is uncontrolled/controlled shall be removed from the Medication carts and destroyed . On 11/06/2018 at 2:54 PM, the surveyor conducted a medication cart review on the second floor. Employee Identifier (EI) #3, LPN/Licensed Practical Nurse was also present. The surveyor observed the following expired medication still on the medication cart: 1. [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review, interview and review of a policy titled Resident Assessment Instrument (RAI), the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed when Resident Identifier (RI) #s 75, 94 and 82 elected to receive hospice benefits. This affected three of seven sampled residents reviewed for hospice, and three of 26 sampled residents for whom MDS assessments were reviewed. Findings Include: A facility policy tilted Resident Assessment Instrument (RAI), dated 11/17/17, documented: .PROCEDURE: . 4. Assessments are also completed for residents who have experienced a Significant Change. Within 14 days after the facility determines, or should have determined, that there has been a significant change .A significant change in status MDS is required when a resident elects . the hospice benefit . [...]
- 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 record review, interview and review of a policy titled Resident Care Planning, the facility failed ensure a care plan was developed when Resident Identifier (RI) #s 82 and 92 elected to receive hospice benefits. This affected two of seven sampled residents reviewed for hospice. Findings Include: A review of a policy titled Resident Care Planing, dated 5/1/2002, revealed: .It is the policy of this facility that a written plan is developed to meet the individual needs of the resident. The services provided or arranged by the facility must meet professional standards of quality and be provided with each resident's written plan of care . 1) RI #82 was readmitted to the facility on [DATE] with a diagnosis of Chronic Pulmonary Disease. A review of a physician order for RI # 82 documented: [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review and review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a licensed nurse followed the physician orders for catheter care provided to Resident Indentifier (RI) #94 on 11/7/18. This affected one of one observation of catheter care. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, copyright date of 2017, page 311, revealed: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI # 94 was readmitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of Bladder. RI # 94's November 2018 Medication Administration Record (MAR) documented the following order for catheter care: [...]
- 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 and interview, the facility failed to ensure expired nutritional supplements were not stored in the medication room. This was observed in one of two medication rooms.
- 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 licensed staff documented in Resident Identifier (RI) #94's medical record that catheter care had been provided twice a day from November 1, 2018 until November 6, 2018. This affected one of 26 sampled residents for whom medical records were reviewed. Findings Include: RI # 94 was readmitted to the facility on [DATE] with a diagnosis to include Neuromuscular Dysfunction of Bladder. RI # 94's November 2018 Medication Administration Record (MAR) documented the following order for catheter care: .Clean supra-pubic catheter site with hydrogen peroxide and pat dry apply Vaseline/TAO (triple antibiotic ointment) to site twice daily and leave open to air . start : 01/25/2017 . There was no documentation of the completion of the catheter care from November 1, 2018 - November 6, 2018. [...]
Fire safety inspections
12 fire safety citations on file: 3 on March 29, 2024, 4 on November 20, 2019, 5 on November 8, 2018.
Every fire safety citation12 citations
- E
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · November 20, 2019 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 20, 2019 · 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 · November 20, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 20, 2019 · 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 · November 8, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 8, 2018 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 8, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 8, 2018 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · November 8, 2018 · Corrected (the home has a date of correction)