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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
25D
8E
0F
Potential for minimal harm
0A
0B
0C
July 28, 2023Standard inspection · 17 citations
- E
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff charged the Resident and deducted from their patient trust account, funds in excess what was due to the facility for three Residents (Resident #17, #37 and #23), in a survey sample of 6 Residents reviewed with trust accounts. This happened on five occasions.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to serve the planned menu as approved by the facility's Registered Dietitian (RD) to residents with physician's orders for regular, mechanical soft, or pureed diets. This failure had the potential to affect 61 residents who were served meals from the facility's kitchen.
- E
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 facility policy review, the facility failed to serve milk from the kitchen's tray line at an internal temperature of 41 degrees Fahrenheit (F.) or below and staff failed to wear hair restraints when they served soup to residents from two crock pots in the facility's main dining room for 25 out of 61 residents who consumed meals prepared at the facility.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to implement infection control practices to prevent the spread of infection on 2 of 2 nursing units, which had the potential to affect multiple Residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to assess for appropriateness of self-administration of medications for 1 Resident (Resident #23) in a survey sample of 44 Residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have call bells accessible for two of two residents (Resident (R)5, and R19) reviewed for accommodation of needs out of 44 sampled residents. These failures had the potential to cause a delay in the provision of care for these two residents.
- 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to offer and/or provide Advance Directive planning for 2 residents, Resident #15 and Resident #44, in a survey sample of 44 residents.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to continue skilled services and bill the Resident as requested on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #14 and #44) in a survey sample of 3 Residents, reviewed for such notices.
- 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 observation, staff interview, and clinical record review, the facility staff failed to review and revise the care plan following a significant weight loss affecting one Resident (Resident #4) in a survey sample of 44 Residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 3 residents, Resident #55, Resident #34, and Resident #52, in a sample size of 44 residents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interviews and clinical record review, the facility staff failed to ensure quality of care based on professional standards and the person-centered care plan was provided for one Resident (Resident #38) in a survey sample of 44 Residents.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide/arrange for one Resident (Resident #13) in a survey sample of 44 Residents to obtain new prescription lenses in her glasses, as ordered.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent the development of pressure ulcers for one Resident (Resident #35) in a survey sample of 44 Residents.
- D
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, interview, record review, and facility policy review, the facility failed to provide splints to address range of motion loss and/or contractures for two of five residents (Resident (R)19, and R5) reviewed for limited range of motion. These failures had the potential to cause worsening contractures for these two residents.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to administer enteral feedings as ordered for one of one sampled Resident (R)213 reviewed for enteral feedings. This failure had the potential to cause weight loss and/or other nutritional complications for this resident.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to implement a system to assure the accurate accounting of controlled medications on 2 of 3 medication carts inspected and failed to ensure medications were available for use for 1 (Resident #55) of 44 sampled residents.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to offer routine dental care for one Resident (Resident #13) in a survey sample of 44 Residents.
April 23, 2021Standard inspection · 3 citations
- E
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, staff interview, and electronic medical record (EMR) review, the facility failed to provide dental services for 4 of 8 residents (Resident (R) 6, R19, R29, R48).
- 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, staff interview, and observation, the facility failed to develop and implement a comprehensive care plan for one of 27 sampled residents (Resident (R) 6) reviewed for care plans. The facility failed to develop a care plan to address R6's dental status/missing teeth.
- D
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 review of facility policy, record review, and staff interviews the facility failed to ensure for one of one resident reviewed for the use of side rails in a sample of 20 residents (Resident (R)3, that R3 had been assessed for the use of side rails, a physician's order had been obtained for the use of side rails, and a care plan developed with specific interventions for the use of the side rails. The assessment for the use of side rails indicated not needed, no physicians order was obtained and no care plan developed for R3.
October 12, 2018Standard inspection · 15 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to prevent and treat pressure wounds for 2 residents (Resident #1 and #35) of 26 residents in the survey sample resulting in harm for Resident #1. 1. For Resident #1, the facility did not provide an air mattress for four months, did not administer a physician order for Flagyl (antibiotic) for nine days and did not obtain a wound consult until ten days after it was ordered by the physician. This resulted in harm. 2. For Resident #35, the facility failed to provide interventions to prevent pressure injuries. Resident #35 had three deep fingernail indentations in the right palm of the Resident's hand that had contractures.
- G
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility failed to, for one resident, Resident #43, in a survey sample of 26 residents, to ensure the resident's mechanical soft diet was followed, resulting in harm. Resident #43 was served cantaloupe chunks instead of a fruit crisp that was on the Registered Dietician's approved menu. As a result of eating a cantaloupe chunk, the resident choked and required the Heimlich maneuver and suctioning.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wrote2. Resident #43 was placed on Seroquel (antipsychotic) 50 mg (milligrams) twice daily for dementia without behavioral disturbance. There is no appropriate diagnosis for use and the medication is associated with increased risk of death in the elderly with dementia. Additionally, there were no care plan interventions to address behaviors or for the continued use of an antipsychotic. Resident # 43 was admitted to the facility 3-4-17. Her diagnoses included but were not limited to: Stroke, dementia and hemiplegia. Resident #43's most recent MDS (minimum data set) with an ARD (assessment reference date) of 9-24-18 was coded as a quarterly assessment. Resident #43 was coded as having a BIMS (Brief Interview for Memory Status) Score of 9 out of 15 indicating moderate cognitive impairment. [...]
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, facility staff interview, clinical record review, and facility documentation review, the facility staff failed for 5 Residents (Resident #23, #13, #28, #53, #43) in a sample of 26 residents to ensure they were free from unnecessary psychotropic medications. 1. For Resident #23, the facility staff failed to ensure he was free from the psychotropic medication Seroquel which is not indicated for residents with the diagnosis of dementia with or without behavioral disturbances. 2. For Resident #13, the facility staff failed to ensure she was free from the psychotropic medication Risperdal which is not indicated for residents with a diagnosis of dementia with behavioral disturbance. 3. [...]
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement an antibiotic stewardship program. The facility staff failed to monitor antibiotic usage and collect outcome data until June, 2018.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, facility staff interview, clinical record review, and facility documentation review, the facility staff failed for Resident #28 of the survey sample of 26 residents, to ensure the right to be informed of treatment risks, and alternatives of psychotropic medications. The facility staff failed to fully inform Resident #28's Responsible Party of the increased risk of death from Seroquel, and possible alternatives.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to obtain a Pre-admission Screening and Resident Review (PASARR) prior to admission for 1 resident (Resident #53) of 26 residents in the survey sample. For Resident #53, the facility did not receive or review the PASARR prior to admission.
- 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, staff interview and clinical record review, the facility failed, for one resident (Resident #35) in a survey sample of 26 residents, to complete a comprehensive care plan. 1. For Resident #35, the facility failed to devise a plan for patient-centered activities pertaining to the potential for sensory deprivation and isolation.
- 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 observation and clinical record review the facility staff failed to revise the care plan for 3 residents (Resident #56, #6, and #13) of 26 residents in the survey sample. 1. Resident #56's care plan did not address pain management. 2. The facility failed to revise the care plan and provide a bed alarm as ordered for Resident # 6. 3. For Resident #13, the facility failed to revise the care plan when the antipsychotic medication was initiated on 09/10/2018.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, staff interviews, record reviews, and facility documentation, the facility failed to assess and provide on-going resident-centered activities for one Resident (Resident #35) out of a sample of 26 residents. Resident #35 was observed to be in his room for 3 days without getting out of bed and with no meaningful activities provided. In addition, between 07/02/2018 through 08/12/2018 the resident only attended two church services, a bible study, and two exercise sessions.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility staff failed to ensure the highest practicable well being for 1 resident (Resident #25) in a survey sample of 26 residents. Resident #25 did not have on her physician ordered TEDS (clot preventing/treatment of edema) stockings during the days of survey.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to provide toileting supervision and implement fall interventions for 2 residents (Resident #56, #6) of 26 residents in the survey sample. 1. Resident #56 required total dependence of one staff while toileting. She was observed alone on the toilet in her room. 2. For Resident #6, the facility failed to implement a bed alarm as a fall intervention.
- 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 observation, staff interview and clinical record review the facility staff failed to implement a toileting program for 1 resident (Resident #56) of 26 residents in the survey sample. Resident #56 was not toileted every 2 hours as ordered.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to provide pain management for 1 resident (Resident #56) of 26 residents in the survey sample. Resident #56 expressed having pain but did not have pain management in place.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on observation, staff interview facility documentation review, the facility pharmacy failed, for 1 resident (#28) to report irregularities in monthly reviews. 1. For Resident #28 the facility pharmacy failed to identify a contraindication with Seroquel and Dementia.
Fire safety inspections
25 fire safety citations on file: 5 on July 28, 2023, 6 on April 23, 2021, 14 on October 12, 2018.
Every fire safety citation25 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 28, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 28, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 28, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · July 28, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 28, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 23, 2021 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 23, 2021 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 23, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · April 23, 2021 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 23, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 23, 2021 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 12, 2018 · Waiver
- E
Install corridor and hallway doors that block smoke.
K 363 · October 12, 2018 · Waiver
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 12, 2018 · Waiver
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 12, 2018 · Waiver
- E
Meet requirements for the use of electrical equipment.
K 919 · October 12, 2018 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · October 12, 2018 · Waiver
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 12, 2018 · Waiver
- D
Meet other general requirements that are deficient.
K 300 · October 12, 2018 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · October 12, 2018 · Waiver
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · October 12, 2018 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 12, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 12, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 12, 2018 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · October 12, 2018 · Corrected (the home has a date of correction)