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 3 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
0E
0F
Potential for minimal harm
0A
0B
0C
February 24, 2022Standard inspection · 0 citations
June 20, 2019Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and review of a facility document titled, Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands prior to administering Resident Identifier (RI) #15's medications, after touching contaminated items, including the door/door knob and privacy curtain. Further, after administering RI #15's medication, the licensed nurse removed her right glove, placed it in the garbage can, and returned to the medication cart, without first washing her hands. This deficient practice affected RI #15, one of three residents observed, and one of three licensed nurses observed during medication pass observations. Findings Include: A review of a facility policy titled, Hand Hygiene with a review date of 11/15/2018 revealed, .PURPOSE To . reduce the transmission of pathogenic microorganisms. PROCESS 1. Perform hand hygiene: [...]
September 13, 2018Standard inspection · 2 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interviews, record review and review of a facility policy titled, Privacy Rights: Patient, the facility failed to ensure a Registered Nurse, Employee Identifier (EI) #2, did not leave Resident Identifier (RI) #52's Medication Administration Record (MAR) visible and unattended exposing RI #52's personal information and medications taken. This was observed on 09/11/18, during the morning medication administration pass. This deficient practice affected RI #52, one of five residents observed during the medication administration pass, and EI #2, one of four nurses observed administering medications. Findings Include: Review of a facility policy titled, Privacy Rights: Patient, with a revision date of 11/18/16, documented: POLICY The patient has a right to personal privacy and confidentiality of his/her personal and medical records. Personal privacy includes . [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review and review of facility policies titled, Medication Administration: Oral and Linen Handling, the facility failed to ensure: 1) a medication nurse, Employee Identifier (EI) #2, sanitized her hands after administering medications to Resident Identifier (RI) #1, and before signing the Medication Administration Record (MAR) on 09/12/18, during the morning medication administration pass; and 2) linen did not touch the uniform of EI #3, a laundry staff member on 09/12/18, when EI #3 was folding the linen (sheets). These deficient practices affected RI #1, one of five residents observed during the medication administration pass, and EI #2, one of four nurses observed administering medications. It also affected EI #3, a laundry staff member and had the potential to affect the resident who would receive that linen. Findings Include: [...]
Fire safety inspections
11 fire safety citations on file: 2 on February 24, 2022, 3 on June 20, 2019, 6 on September 13, 2018.
Every fire safety citation11 citations
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · February 24, 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 · February 24, 2022 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 300 · June 20, 2019 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · June 20, 2019 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 20, 2019 · Waiver
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 13, 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 13, 2018 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 13, 2018 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · September 13, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 13, 2018 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 13, 2018 · Corrected (the home has a date of correction)