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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
4D
0E
4F
Potential for minimal harm
0A
0B
1C
October 14, 2024Standard inspection · 8 citations
- F
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents. Based on observation, record review, and interviews, the facility failed to post the required information including a list of names, addresses (mailing and e-mail), and telephone numbers of all pertinent State Agencies and advocacy groups. This deficient practice placed all residents at risk for impaired resident rights.
- F
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 10/14/24 at 01:48 PM an inspection of the facility revealed a posting in an empty resident room that directed if a resident had a concern, they were to call the facility's patient advocate. A Resident Rights poster was located near the nurse's station; however, it did not have directions on how to file anonymous grievances. The inspection revealed there was no submission box or method for filing anonymous grievances. [...]
- F
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents. Based on record review and interviews, the facility failed to establish and implement an admissions agreement that protected the residents' right to personal property. This deficient practice had the risk of loss of personal property, including property of monetary and/or sentimental value, and loss of dignity and personal right to property for residents admitted to the facility.
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents. Based on record review and interviews, the facility failed to develop a facility assessment that accurately reflected the required sections of a facility assessment including services provided, staff required, staff competencies, and religious practices. This deficient practice placed the residents at risk for unidentified care needs and inadequate care and services.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents with one resident reviewed for hospitalization. Based on record review and interviews, the facility failed to provide written notification within a practicable timeframe of a facility-initiated transfer to Resident (R) 3 or his representative. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for R3. This deficient practice had the risk of miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services for R3, and placed R3 at risk for impaired rights.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents with one resident reviewed for hospitalization. Based on record review and interviews, the facility failed to establish a bed hold policy and provide written notification of the bed hold policy to Resident (R) 3 or his representative. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R3.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents with five residents reviewed for pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on observations, record review, and interviews, the facility failed to administer a pneumococcal vaccination to Resident (R) 107 after he consented to receive it on 09/26/24. This deficient practice placed R107 at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteThe facility identified a census of nine residents. The sample included eight residents. Based on observation, record review, and interviews, the facility failed to post, in a place readily accessible to residents, family members, or legal representatives, the results of the most recent survey of the facility; failed to have the last three years of survey results available; and failed to post a notice of the availability of such reports in areas of the facility that were prominent and accessible to the public. This deficient practice placed the residents at risk for impaired resident rights.
June 21, 2023Standard inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility identified a census of ten residents. The sample included eight residents with five reviewed for medication administration. Based on observations, record review, and interviews, the facility failed to follow sanitary infection control practices while performing blood glucose checks on Resident (R)108. This deficient practice placed R108 at risk for complications related to infections. Findings Included- - On 06/20/23 08:12 AM Licensed Nurse (LN) G entered R108's room, already wearing gloves, carrying the glucometer (instrument used to calculate blood glucose) and other supplies in her hand. LN G announced herself and told R108 she would be checking R108's blood sugar. LN G walked over to R108's bedside table and placed the glucometer and other supplies down, directly on the bedside table with no clean barrier or sanitization of the table. [...]
December 22, 2021Standard inspection · 0 citations
Fire safety inspections
14 fire safety citations on file: 5 on October 14, 2024, 3 on June 21, 2023, 6 on December 22, 2021.
Every fire safety citation14 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 14, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · October 14, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 14, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · October 14, 2024 · Corrected (the home has a date of correction)
- F
Ensure that anesthesia apparatus are tested after any adjustment, modification or repair.
K 924 · October 14, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 22, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · December 22, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · December 22, 2021 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · December 22, 2021 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · December 22, 2021 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 22, 2021 · Corrected (the home has a date of correction)