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 6 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
0E
0F
Potential for minimal harm
0A
0B
0C
September 19, 2024Standard inspection · 0 citations
November 18, 2022Standard inspection · 2 citations
- 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 observations, interviews and record review conducted during a Recertification Survey completed on 11/18/22, it was determined that for one (Resident #32) of three residents reviewed for pressure ulcers, the facility did not revise the resident's care plan to reflect the resident's current needs. Specifically, Resident #32's Comprehensive Care Plan (CCP) and Certified Nursing Assistant (CNA) Closet Care Card were not revised to include the use of a knee immobilizer, interventions for pressure ulcer prevention, or current interventions for an actual pressure ulcer. This is evidenced by the following: The facility policy Nursing Care Plan/Profile, dated reviewed December 2021 documented that an individualized Nursing Care Plan/profile shall be created for each resident, and they are reviewed and/or revised whenever the resident's condition warrants or at least every 90 days. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, completed on 11/18/22, it was determined that for one (Resident #32) of three residents reviewed for pressure ulcers, the facility did not ensure the resident received the necessary treatment to promote healing of a pressure ulcer, prevent infection and prevent new ulcers from developing. Specifically, the facility could not provide evidence that physician orders related to a knee immobilizer were implemented or that skin evaluations were completed in a timely manner to avoid potential skin issues. This is evidenced by the following: Review of the facility's policy Skin Monitoring Protocol, dated December 2021, revealed that all skin conditions will be assessed, documented and tracked on a weekly basis. [...]
June 18, 2021Standard inspection · 4 citations
- 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 observations, interviews, and record reviews conducted during the Recertification Survey, completed on [DATE], it was determined that for three (Residents #2, #42, and #92) of five residents reviewed, the facility did not ensure that information regarding residents' wishes for advance directives was consistently and accurately documented. Specifically, Resident's #2 and Resident #92's wishes included Cardiopulmonary Resuscitation (CPR) but physician orders were for Do Not Resuscitate (DNR), and #42's wishes included DNR, but their medical record identified their wishes were for CPR. This is evidenced by the following: [...]
- 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 observations, interviews and record reviews conducted during a Recertification Survey, completed on 6/18/21, it was determined that for 2 (Residents #26 and #66) of 21 residents the facility did not ensure a person-centered care plan was developed and implemented that addressed the residents' medical, physical, mental and psychosocial needs. Specifically, Resident #26's Comprehensive Care Plan (CCP) was not implemented to ensure their safety related to resident to resident altercations, and Resident #66's CCP did not address or implement escalating behaviors and non-pharmacological interventions for staff to utilize. This was evidenced by: The facility policy Cognitive Loss/Dementia, dated January 2021, directs staff to develop a resident centered, individualized care plan, focused on quality of life in order to maintain each resident's dignity and confidentiality. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 6/18/21, it was determined for one (Resident #85) of four residents reviewed, that the facility did not ensure the resident's environment was free from accident hazards and that the resident received adequate supervision to prevent accidents. Specifically, the resident ingested hazardous substances on two occasions and the incidents were not investigated or interventions initiated to prevent re-occurrences. This is evidenced by the following: Resident #85 had diagnoses including Lewy body dementia, a history of alcoholism, restlessness and agitation. [...]
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 6/18/21, for one (Resident #29) of two residents reviewed, the facility did not ensure the resident received the appropriate treatment and services to attain or maintain their highest practical physical, mental and psychosocial well-being. Specifically, the facility did not develop a comprehensive person-centered care plan with measurable goals and interventions to address the care and services for the resident related to their dementia and behaviors. This is evidenced by the following: The facility policy, A Policy and Procedure for Dementia Care, dated January 2021 documented that the facility will provide residents with the necessary care and services according to the plan of care. [...]
Fire safety inspections
6 fire safety citations on file: 2 on September 19, 2024, 2 on November 18, 2022, 2 on June 18, 2021.
Every fire safety citation6 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 19, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · November 18, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 18, 2022 · Corrected (the home has a date of correction)
- E
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 18, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 18, 2021 · Corrected (the home has a date of correction)