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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
1L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
4E
0F
Potential for minimal harm
0A
0B
0C
May 28, 2024Complaint inspection · 1 citation
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interviews, the facility failed to ensure three residents (Resident #2, #4, and #5) /resident representatives were refunded within 30 days from the residents' date of discharge from the facility.
March 13, 2024Standard inspection · 6 citations
- 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, record review, and interview, the facility failed to ensure medications with shortened shelf life once opened were dated in three (100, 200/500, and 600) out of six medication carts, failed to ensure two medications in pre-filled syringes were not stored mixed together in one (600) out of six medication carts and one (300/400) out of three medication rooms, and expired medications had been removed from two (300 and 600) out of six medication carts. The facility failed to ensure medications were not left unattended and inaccessible to unauthorized staff, residents, and visitors for three (Residents #98, #74, and #314) of 45 sampled residents.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for three (Residents #14, #26, and #83) out of thirty-two residents initially sampled to include review of their PASRR's.
- 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, record review, and interview, the facility failed to allow one (Resident #94) of three residents sampled for care planning, to participate in developing and revising their care plan related the side rails.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain a physician order prior to administering oxygen for one (Resident #273) of two residents reviewed for oxygen.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure staffing posting information was up-to-date and current.
- 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 ensure medications for two (Residents #78 and #83) of eleven residents observed during the administration of medications and reviewed for the appropriateness of medications had received medications within the parameters set by the physician.
January 3, 2024Complaint inspection · 2 citations
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pain was managed effectively for three residents (#4, #5, and #3) out of three residents sampled for pain management.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for three residents (#4, #5, #6) out of four sampled residents who were administered medications. This resulted in 19 errors from 20 medication administration opportunities for a medication error rate of 95%. Findings Included: An observation was conducted on 1/3/24 at 9:36 a.m. of Staff D, Registered Nurse (RN) preparing and administering medication for Resident #4. Staff D, RN prepared the following medications: [...]
December 10, 2021Standard inspection · 4 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to identify skin conditions by not ensuring weekly skin assessments were completed for one resident (#41) out of thirty-eight sampled residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews and record review the facility did not ensure a resident's dignity was respected related to not providing a privacy bag for a catheter drainage bag for one resident (#346) of two sampled residents for catheter care.
- 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, policy review, and interview the facility failed to ensure medications were disposed of when expired, failed to ensure medicated eye drops were dated when opened and failed for two medication carts (300 Hall and 100/500 Hall) and failed to ensure one medication cart (300 Hall) was organized and uncluttered of five medication carts.
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure one resident (#37) received physician ordered laboratory services related to obtaining a urinalysis out of thirty-eight sampled residents.
September 25, 2020Standard inspection · 3 citations
- L
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews with the Nursing Home Administrator(NHA), the Director of Nursing (DON), Assistant Director of Nursing (ADON), nursing staff, the resident's attending physician/Medical Director, and review of clinical records, policies and procedures it was determined that the facility failed to provide an environment that remained as free of accident hazards as possible and ensured residents were safe from burns from scalding hot liquids served during meals. Failure to maintain safe hot liquid temperatures caused hot liquid burns on two Residents #3 & #57 on 9/2/20, who requested hot liquids. Both residents required supervision of one person for eating and drinking. After learning of the two hot liquid burns on 9/2/20, the facility failed to investigate the temperatures of scalding hot liquids for 21 days from 9/2/20 until 9/23/20. [...]
- J
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interviews with the Nursing Home Administrator (NHA)/Risk Manager, Director of Nursing (DON), and Assistant Director of Nursing (ADON), Nursing staff, the attending Physician/Medical Director, record review of resident #3 and #57's medical record, review of the facility's policies, the facility's Administration failed to utilize its resources effectively by failing to investigate and act on two documented burn injuries for residents #3 and #57. A total of 52 out of 55 residents had the potential to request hot liquids. The facility documented the hot liquid burns for 9/2/20 on the event log for September then failed to investigate and remove the burn risk potential for 52 of 55 residents. [...]
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to promote and facilitate resident self-determination for one (#64) of 15 sampled residents. The facility did not ensure that Resident #64's contracted choice to have a private room was honored.
Fire safety inspections
8 fire safety citations on file: 3 on March 13, 2024, 5 on September 25, 2020.
Every fire safety citation8 citations
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 13, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 13, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 13, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 25, 2020 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · September 25, 2020 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 25, 2020 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 25, 2020 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 25, 2020 · Corrected (the home has a date of correction)