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 3 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
2D
1E
0F
Potential for minimal harm
0A
0B
0C
February 17, 2022Standard inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and a review of facility policies titled MEAL SERVICE and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to ensure staff changed gloves and performed hand hygiene during meal delivery and pick up. On 2/14/22 during the supper meal delivery in the downstairs dining room, Employee Identifier (EI) #5 Certified Nursing Assistant (CNA) was observed to deliver a supper tray to Resident Identifier (RI) #2 and RI #11 without changing gloves or performing hand hygiene before each resident's tray delivery and set up. On 2/15/22 during the breakfast meal tray pick up, EI #6, Staffing Coordinator, picked up breakfast trays from RI #251 and RI #31 without performing hand hygiene after each resident's tray was removed from their rooms. [...]
- 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, interviews, and a review of the facility policy Medication Administration, the facility failed to ensure Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), one of three licensed staff observed with a medication cart, did not leave a medication cart unlocked and unattended on 2/15/22, one of four days of the survey. This affected one of two medication carts in the facility and had the potential to affect all 23 residents on level one whose medications were in the medication cart left unlocked and unattended. Findings Include: A review of a facility policy titled Medication Administration with an effective date of February 2021 revealed, . Policy Explanation and Compliance Guidelines: . 4. Medication cart will be locked or under direct observation of authorized associates. RI #11 was readmitted to the facility on [DATE]. [...]
June 6, 2019Standard inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, medical record review, interview and review of a facility policy titled, Clean Dressing Change, the facility failed to ensure a Licensed Practical Nurse (LPN)/Wound Nurse, Employee Identifier (EI) #2, washed her hands and put on clean gloves after cleaning the sacral wound and prior to applying Silvermed Hydrogel (wound treatment gel) to the wound bed during the provision of wound care for Resident Identifier (RI) #43 on 06/05/2019. This affected RI #43, one of two sampled residents observed during the provision of wound care.
May 10, 2018Standard inspection · 0 citations
Fire safety inspections
5 fire safety citations on file: 3 on February 17, 2022, 1 on June 6, 2019, 1 on May 10, 2018.
Every fire safety citation5 citations
- F
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 · February 17, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 17, 2022 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 17, 2022 · 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 · June 6, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 10, 2018 · Corrected (the home has a date of correction)