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
3G
0H
0I
Potential for more than minimal harm
3D
0E
0F
Potential for minimal harm
0A
0B
0C
July 16, 2024Standard inspection · 4 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#67) of three residents reviewed for pressure-related skin conditions out of 32 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #67, who was at risk for developing pressure injuries due to paraplegia, weakness and the inability to move both legs, was admitted on [DATE]. The facility provided a pressure reducing mattress and wheelchair pad upon admission. The resident was able to make small movements to reposition herself, however, the staff did not provide the resident with consistent repositioning per the resident's needs On 7/4/24, a wound was observed on the resident's sacral area (bony area just above the tailbone). [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#6) of nine residents reviewed for accidents out of 32 sample residents remained as free from accident hazards as possible. The facility failed to prevent Resident #6's fall from a mechanical (hoyer) lift while transferring her. On [DATE] two certified nurse aides (CNA) #1 and #3 attempted to transfer Resident #6 from her bed to her wheelchair. During the transfer, Resident #6 fell from the sling attached to the mechanical lift's sling bar (a bar with two safety latches on each end the sling attaches to), onto the floor and hit her head on the mechanical lift. As a result, Resident #6 sustained head trauma (laceration) to the back of her head. Immediately after Resident #6's fall staff observed that one (right upper body) of the four sling handles had disconnected from the mechanical lift sling bar. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one resident (#44) of three residents reviewed for blood pressure management out of 32 sample residents. Specifically, the facility failed to assess and document Resident #44's blood pressure consistently prior to administering blood pressure medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to: -Ensure licensed practical nurse (LPN) #3 followed proper infection control during medication administration; and, -Follow proper infection control procedures by sanitizing scissors pulled from a nurses pocket prior to their use for Resident #21's wound care.
February 14, 2023Standard inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#51) of five out of 29 sample residents were kept free from neglect and abuse. Specifically, the facility failed to ensure Resident #51, who required extensive assistance from two staff for toileting, was not left on the toilet commode for 70 minutes on 1/12/23.
October 21, 2021Standard inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteII. Resident #27 A. Resident status Resident #27, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 CPO, pertinent diagnoses included muscle weakness, difficulty in walking, cognitive communication deficit, attention and concentration deficit; and new diagnoses on 10/2/21 of non-displaced fracture of base of second metacarpal (bones between the wrist and fingers) left hand, and displaced fracture of shaft of third metacarpal bone left hand. The 9/15/21 MDS indicated Resident #27 was severely cognitively impaired with a BIMS score of three out of 15. She did not have mood or behavior symptoms. She required extensive assistance of two staff members for bed mobility, transfers and toilet use, and required extensive assistance of one staff member for personal hygiene and dressing. [...]
Fire safety inspections
7 fire safety citations on file: 2 on July 16, 2024, 4 on February 14, 2023, 1 on October 21, 2021.
Every fire safety citation7 citations
- D
Provide properly protected cooking facilities.
K 324 · July 16, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 16, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 14, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 14, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 14, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 14, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · October 21, 2021 · Corrected (the home has a date of correction)