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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
0F
Potential for minimal harm
0A
0B
0C
July 3, 2024Standard inspection, Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 2 of 18 sampled residents (Resident #157 and #11).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the medical provider orders for 1 of 14 sampled residents (Resident #46).
January 21, 2022Standard inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide treatment and care in accordance with the comprehensive person-centered care plan for one of 17 residents in the survey sample, Resident #2. For Resident #2, the facility staff failed to follow the physician's order for the administration of Diltiazem, a medication used to treat high blood pressure and control chest pain.
March 4, 2020Standard inspection · 2 citations
- J
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, resident interview, staff interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure implementation of infection control practices and precautions to prevent the spread of infection and communicable disease during an identified occurence of a respiratory illness. A facility staff member entered a resident room that was positive for the flu with no PPE (personal protective equipment) in place; failed to perform any hand hygiene prior to leaving this room; failed to implement the requirment for droplet precautions; failed to ensure the staff and surveyor were aware of who had the flu; and failed to ensure a visitor was given education in regards to wearing PPE when visiting a resident on contact isolation for 6 of 25 residents (Residents #15, #19, #32, #44, #45, and #59). [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. For Resident #160, the facility staff failed to follow physicians orders in regards to the administration of Lasix, Belsomra, and Lyrica. This was a closed record review. The clinical record was reviewed on 03/02 and 03/03/2020. The face sheet located in the clinical record included the diagnoses essential hypertension, chronic atrial fibrillation, and aftercare following joint replacement surgery. Section C (cognitive patterns) of the residents 5 day assessment with an ARD (assessment reference date) of 05/21/2019 included a BIMS (brief interview for mental status) summary score of 14 out of a possible 15 points. The residents clinical record included the following physician orders. Belsomra tablet 10 mg 1 tablet by mouth at bedtime for insomnia, Lasix 20 mg give 1 tablet by mouth in the evening for edema, and Lyrica capsule 75 mg by mouth at bedtime for pain. [...]
Fire safety inspections
13 fire safety citations on file: 3 on July 3, 2024, 10 on January 21, 2022.
Every fire safety citation13 citations
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 3, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 3, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 3, 2024 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · January 21, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 21, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · January 21, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 21, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 21, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 21, 2022 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 21, 2022 · 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 · January 21, 2022 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · January 21, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · January 21, 2022 · Corrected (the home has a date of correction)