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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
5D
21E
1F
Potential for minimal harm
0A
0B
0C
January 16, 2025Complaint inspection · 1 citation
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an effective pest control program. The DON identified 52 residents resided in the facility.
December 19, 2024Standard inspection · 1 citation
- E
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 observation, record review and interview, the facility failed to ensure: a. a diuretic was included on the care plan for one (#23) of five sampled residents reviewed for unnecessary meds; and b. assist rails were included on the care plan for one (#43) of two sampled residents reviewed for restraints. The administrator in training identified 51 residents resided in the facility and 15 residents received diuretics. MDS Coordinator #1 identified three residents had assist rails.
October 8, 2024Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteOn 10/07/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff followed proper procedure for the use of a mechanical lift to prevent accidents. The failure resulted in a fractured hip for Res #1. An undated facility Hydraulic Lift policy documented to check to be sure hooks are secure. A care plan intervention, dated 11/03/23, documented Res #1 required two staff assistance with a Hoyer (full body mechanical lift) for transfers. On 09/08/24, Res #1 had a fall due to the strap on the transfer sling failing to remain attached to the Hoyer lift. The resident was sent to the hospital and diagnosed with a closed hip fracture. Staff were in-serviced on 09/08/24 regarding lift safety and operation, but no ongoing monitoring was completed to ensure staff compliance with safe utilization of mechanical lifts. [...]
October 12, 2023Standard inspection, Complaint inspection · 12 citations
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on record review and interview, the facility failed to submit PBJ data to CMS for the third quarter of the fiscal year for 2023. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility. Findings The PBJ Staffing Data Report documented the facility failed to submit data for the third quarter of 2023 (April 1 - June 30). On 10/10/23 at 9:43 a.m., the BOM was asked how often the facility submitted staffing data to CMS. They stated quarterly. They were asked if they had submitted data for the third quarter of 2023. 10/10/23 at 11:18 a.m., the BOM stated they did not submit the data for the quarter and should have.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessment were accurate and/or completed timely for two (#6 and #44) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly assessments were completed once every three months and/or no later than 14 days after the ARD for two (#6 and #36) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility.
- E
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 and interview, the facility failed to fully develop comprehensive care plans for four (#6, 8, 44, and #47) of 13 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility.
- E
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 observation, record review, and interview, the facility failed to review and/or revise the care plan related to: a. a decrease in mobility for one (#3) of 13 residents whose care plans were reviewed, and b. fall prevention interventions for one (#28) of 13 residents who were reviewed for accidents. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, record review, and interview, the facility failed to provide nail care for one (#34) of two sampled residents reviewed for activities of daily living. The Resident Census and Conditions of Residents report, dated 10/10/23, documented 46 residents resided in the facility.
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review, and interview, the facility failed to turn and reposition a resident with limited range of motion (ROM) in order to increase ROM and/or prevent further decline for one (#1) of three residents reviewed for mobility. The Resident Census and Conditions of Residents report, documented 44 residents who required assistance with mobility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent falls for one (#39) of three sampled residents reviewed for accidents. The facility failed to consistently implement interventions to prevent recurrence and evaluate interventions for effectiveness for a resident who had frequent falls. The Resident Census and Conditions of Resident report documented 46 residents resided in the facility.
- 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 wroteBased on observation, record review, and interview, the facility failed to: a. attempt appropriate alternatives prior to installing bed or side rails; b. perform an entrapment risk assessment; c. review the risks or benefits with the resident and/or their representative; d. obtain an informed consent; and e. develop a care plan for side rail use for one (#39) of three sampled residents reviewed for accident hazards. The DON identified 16 residents whose beds were equipped with a bed rail of any type.
- E
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 conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#39) of three residents reviewed for accident hazards. The DON identified 16 residents whose beds were equipped with a bed rail of any type.
- 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 interview, the facility failed to ensure physician orders were obtained for code status for two (#26 and #1) of 13 sampled residents reviewed for code status. The DON identified 23 residents who were DNR's.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on record review and interview, the facility failed to ensure a significant change in status MDS was completed timely by the 14th calendar day after the determination the significant changes has occurred for one (#26) of 13 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 10/10/23, docuented 46 residents resided in the facility.
December 8, 2022Standard inspection · 14 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observation, and interview, the facility failed to notify the physician of an unstageable pressure ulcer, provide appropriate treatment, and provide wound care in a way to help prevent infection for one (#33) of two residents reviewed for pressure ulcers. The facility documented an unstageable ulcer on 11/04/22 and the physician was not notified. On 12/07/22, during an observation of wound care, an additional pressure ulcer was observed. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents resided in the facility who had pressure ulcers.
- E
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 review, observation, and interview, the facility failed to notify the physician of a new pressure ulcer for one (#33) of two residents reviewed for pressure ulcers. The Resident Census and Condition of Residents report, dated 12/06/22, documented two residents had pressure ulcers in the facility.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure assessments accurately reflected the residents status for three (#10, 29, and #32) of 14 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for one (#1) of one resident who was reviewed for ADLs. The Resident Census and Condition of Residents report, dated 12/06/22, documented 43 residents resided in the facility.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation, and interview, the facility failed to assess for risks associated with smoking for one (#42) of one resident sampled for smoking. RN #1 identified three residents who smoked.
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, observation and interview, the facility failed to provide physician ordered weekly weights for one (#29) of two residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents with unplanned weight loss or gain. The RN provided documentation of 15 residents who were to receive weekly weights.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff completed required competency demonstrations annually. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility.
- E
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 record review and interview, the facility failed to ensure a registered nurse served in the facility for at least eight consecutive hours a day, seven days a week. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility.
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on record review and interview, the facility failed to obtain labs as ordered by the physician for one (#6) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to perform proper hygiene during wound care for one (#33) of one observed for wound care and perform proper hand hygiene when delivering meals to residents. The Resident Census and Condition of Residents report, dated 12/06/22, documented 43 residents resided in the facility.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to: a. offer the influenza vaccination to each resident annually for two (#27 and #38) and b. administer the pneumococcal immunization for two (#2 and #6) of five sampled residents reviewed for influenza and pneumococcal immunizations. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview, the facility failed to ensure a quarterly assessment was completed no later than 14 days after the ARD for one (#10) of 14 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 12/06/22, documented 43 residents resided in the facility.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to transmit MDS assessments to CMS within seven days of completion for one (#19) of one resident sampled for assessment transmission. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility.
- 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, observation, and interview the facility failed to revise a care plan related to pressure ulcers for one (#33) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 12/06/22, documented two residents have pressure ulcers.
Fire safety inspections
4 fire safety citations on file: 1 on December 19, 2024, 3 on October 12, 2023.
Every fire safety citation4 citations
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · December 19, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 12, 2023 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 12, 2023 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 12, 2023 · Corrected (the home has a date of correction)