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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
1E
2F
Potential for minimal harm
0A
0B
2C
November 4, 2024Standard inspection · 7 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review, observation, resident interview, staff interview, review of the facility policy, and review of online guidance per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure residents with pain from pressure ulcers were assessed and medicated for pain before, during and after wound care. Actual Harm occurred for Resident #142 when staff failed to assess Resident #142 for pain prior to wound care. Resident #142 reported she was experiencing severe pain prior to wound care and during wound care and the resident moaned and grimaced during the treatment while staff failed to assess for pain and/or offer pain medication or to pause the treatment. This affected one (Resident #142) of three residents reviewed for pain. [...]
- F
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 kitchen record review, observation, staff interview, review of the facility policy, and medical record review, the facility failed to prepare foods as planned by the Registered Dietitian (RD). This had the potential to affect all of the residents residing in the facility. The facility census was 29 residents.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure staff performed appropriate hand hygiene during meal service. This affected seven (Residents #13, #20, #141, #145, #146, #199, #200) of eight residents observed for meal service. The facility also failed to store, label and serve food under sanitary conditions and had the potential to affect all of the residents residing in the facility. The facility census was 29 residents.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff administered medications in a sanitary manner. This affected one (Resident #142) of three residents reviewed for medication administration. The facility also failed ensure residents with wounds were placed in enhanced barrier precautions (EBP.) This affected nine (Residents #10, #146, #142, #200, #201, #198, #144, #202, and #199) of ten facility-identified residents with wounds. The facility also failed to ensure staff performed proper hand hygiene after blood glucose monitoring. This affected one (Resident #30) of one resident reviewed for blood glucose monitoring. The facility also failed to proper hand hygiene was performed during and after wound care. This affected one (Resident #142) of one resident reviewed for wound care. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were treated with dignity and respect. This affected one (Resident #142) of 13 residents sampled. The facility census was 29 residents.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure intravenous (IV) therapy was administered in accordance with professional standards of practice. This affected one (Resident #143) of two facility identified residents receiving IV therapy. The facility census was 29 residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen tubing was dated. This affected two (Residents #145 and 143) of three facility-identified residents who required oxygen routinely. This facility census was 29 residents.
August 24, 2021Standard inspection · 6 citations
- 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 medical record review, staff interview and review of facility policy, the facility failed to implement a pharmacy recommendation by ensuring an antidepressant was decreased timely when approved by the physician. This affected one resident (#118) of three residents reviewed for unnecessary medication. The facility census was 36.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review, staff and hospital staff interview, observations and facility policy review, the facility failed to ensure a resident was free from unnecessary medications when the staff failed to monitor lab levels as ordered. This affected two (#118 and #125) of five residents reviewed for medication monitoring. The facility census was 36.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, observation, staff and resident interview, and review of facility policy, the facility failed to administer insulin as ordered by the physician resulting in a significant medication error. This affected one (#175) of three residents reviewed for medication administration. The census was 36.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, staff interview, review of facility policy, and review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), the facility failed to ensure staff wore appropriate eye protection to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). Additionally, the facility failed to ensure staff used proper infection control practices during medication administration. This affected one (#175) of three residents observed for medication administration. The census was 36.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on resident and staff interviews, observations and review of facility policy, the facility failed to post the results of the most recent survey and ensure residents were made aware of the availability of survey results. This had the potential to affect all 36 residents residing in the facility. The census was 36.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations and staff interview, the facility failed to post the daily staffing in the facility. This had the potential to affect all residents residing in the facility. The census was 36.
February 21, 2019Standard inspection · 0 citations
Fire safety inspections
8 fire safety citations on file: 1 on November 4, 2024, 4 on August 24, 2021, 3 on February 21, 2019.
Every fire safety citation8 citations
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · November 4, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 24, 2021 · Corrected (the home has a date of correction)
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · August 24, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 24, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 24, 2021 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · February 21, 2019 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 21, 2019 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 21, 2019 · Corrected (the home has a date of correction)