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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
3F
Potential for minimal harm
0A
0B
0C
September 7, 2023Standard 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 observations, interviews, the facility's policies for Food Receipt and Storage, Insect and Rodent Control, Hand Sanitation During Dishwashing, and Hand-washing Guidelines, the facility's Pest Elimination Services Agreement, the facility's Pest Elimination Scope of Service, the facility's pest control service reports, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to prevent potential cross contamination by not ensuring: [...]
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, the facility's policy for Garbage and Refuse, a waste management invoice for the facility, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to ensure three of three dumpsters were not filled to overflowing with plastic bags of garbage/trash, with the dumpster lids open, and with four plastic bags of garbage/trash on the pavement beside the dumpsters on 09/05/2023 at 4:23 PM. This had the potential to affect 103 of 103 residents residing in the facility.
- 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 resident record review, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #8 the breakfast meal on 09/06/2023. This deficient practice had the potential to affect RI #8, one of one resident sampled for dignity.
October 29, 2019Standard inspection · 2 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 and a review of a facility policy titled, Leftover Food Storage and Use, the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler, and 2. food items were labeled with a receive date or use by date prior to storage in the walk-in cooler/walk-in freezer. These failures had the potential to affect 99 residents receiving meals from the kitchen out of 103 total residents residing in the facility. Findings Include: The facility policy titled, Leftover Food Storage and Use, with an effective date of 9/12/19, included . PURPOSE: To assure that food borne illnesses are avoided . Leftover foods should be . labeled and dated . should be used within 72 hours . If not used within 72 hours . foods should be discarded . On 10/27/19 at 10:22 a.m., the surveyor observed food items in the walk-in cooler. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and a facility policy titled Respiratory Therapy, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN), rinsed with water and dried Resident Identifier (RI) #33's nebulizer facemask and attached reservoir, prior to placing it in a plastic bag on the bedside table. This deficient practice affected RI #33, one of three residents observed during the medication pass, and EI #1, one of three nurses observed during the medication pass. Findings Include: A review of a facility policy titled, Respiratory Therapy, with a date of 03/2011, revealed . Nebulizers . C. After completion of therapy: (1) Remove nebulizer container. (2) Rinse container with fresh tap water. (3) Dry appropriately . [...]
September 12, 2018Standard inspection · 2 citations
- E
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, and facility policies titled, Nursing Pantry foods, and Food Storage Temperature Logs, the facility failed to ensure: 1. unit refrigerator temperatures were being monitored and 2. food items brought in from outside of the facility were dated. This effected 2 of 3 unit refrigerators. 1. A review of the facility policy titled, Food Storage Temperature Logs, with an effective date of 04/29/2015, revealed, Purpose: In order to prevent food borne illnesses, foods should be stored at proper temperatures. STANDARD: The FDA (Food and Drug Administration) Food Code guidelines should be used for the storage of food items. Temperatures should be monitored and recorded on a food temperature log. Process . Refrigerators 33-40 degrees F . An observation was made on 09/11/18 11:42 AM of the resident refrigerator on Station 2. [...]
- 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 interview, medical record review and the Resident Assessment Instrument User [NAME] Version 3.0, Chapter 4, the facility flied to ensure RI (Resident Identifier) #77, #29, and #4 attended their care plan meetings so that they were allowed to be involved with making decisions about their care and treatment. This deficient practice affected three of three sample residents whose care plan attendance form was reviewed. Findings Include: A review of a document, Resident Assessment Instrument User [NAME] Version 3.0, revealed: Chapter 4: .CARE PLANNING .4.7 Care Planning .A well developed .care plan, Reflects the resident/resident representative input for goals for health care; .The overall care plan should be oriented towards .Involving resident, resident's family . [...]
Fire safety inspections
13 fire safety citations on file: 6 on September 7, 2023, 2 on October 29, 2019, 5 on September 12, 2018.
Every fire safety citation13 citations
- F
Include a process for Emergency Preparedness collaboration.
E 9 · September 7, 2023 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · September 7, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 7, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 7, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · September 7, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · September 7, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 29, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 29, 2019 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · September 12, 2018 · 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 · September 12, 2018 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 12, 2018 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · September 12, 2018 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · September 12, 2018 · Corrected (the home has a date of correction)