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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
1E
1F
Potential for minimal harm
0A
0B
0C
October 31, 2024Standard inspection · 4 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents with eight reviewed for accidents. Based on observation, interview, and record review the facility failed to identify causative factors for falls and implement meaningful, resident-centered interventions, including adequate supervision, to prevent falls for Resident (R) 13 who experienced repeated falls in the past year. The facility failed to assess interventions that were in place to ensure the interventions were appropriate and to monitor the effectiveness of the interventions. This deficient practice placed R13 at risk for ongoing falls and injuries.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for the use of an antipsychotic (a class of medications used to treat a mental disorder characterized by gross impairment testing) or the required physician documentation for two of five residents, Resident (R) 26, and R31, reviewed for unnecessary medications. This placed the residents at risk for unnecessary psychotropic (alters mood or thought) medications.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents with two reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)16 and R11. This placed the residents at risk for inadequate end-of-life care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure staff followed appropriate infection control standards related to a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) care for Resident (R) 19. This deficient practice placed R19 at increased risk for infections.
June 19, 2023Standard inspection · 3 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteThe facility had a census of 45 residents. Based on observation, interview, and record review the facility failed to employ a certified dietary manager to supervise the preparation of meals and organization in the facility's kitchen. This deficient practice placed the 45 residents who received meals from the kitchen at risk for receiving inadequate nutrition.
- 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 wroteThe facility had a census of 45 residents. The sample included 12 residents with one reviewed for accidents. Based on observation, interview, and record review the facility failed to review or revise Resident (R)37's care plan with interventions which addressed the causative factor to prevent further falls after he slid out of his recliner or off his bed numerous times. This deficient practice placed R37 at risk for injuries related to falls.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents with one reviewed for accidents. Based on observation, interview, and record review the facility failed to provide interventions which addressed the causative factor to prevent further falls for Resident (R) 37 after he slid out of his recliner or off his bed numerous times. This deficient practice placed R37 at risk for injuries related to falls.
October 13, 2021Standard inspection · 3 citations
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteThe facility had a census of 48 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals in a safe manner in one of three medications carts.
- 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 wroteThe facility had a census of 48 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to report to the Director of Nursing, medical director, or physician the lack of a proper diagnosis for one of five sampled residents, Resident (R) 41's Seroquel (class of medications used to treat major mental disorder characterized by a gross impairment in reality and other mental emotional conditions).
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to identify an inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for three of five sampled residents, Resident (R) 47, R48 and R41.
Fire safety inspections
21 fire safety citations on file: 10 on October 31, 2024, 4 on June 19, 2023, 7 on October 13, 2021.
Every fire safety citation21 citations
- F
Meet other general requirements.
K 100 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of highly flammable decorations.
K 753 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 31, 2024 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 19, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 19, 2023 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · June 19, 2023 · 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 · June 19, 2023 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 13, 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 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 13, 2021 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · October 13, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 13, 2021 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 13, 2021 · Corrected (the home has a date of correction)