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
5D
4E
0F
Potential for minimal harm
0A
0B
0C
November 7, 2024Standard inspection · 5 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, four errors occurred resulting in a 14.81% error rate (Residents #31, #10, #12 and #88). The census was 123 with 99 residents in certified beds. Review of the facility's Administering Medications policy, review date 1/30/24, showed: -Purpose: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide resident with the necessary medication(s) when they leave the community temporarily; -Policy Interpretation and Implementation: 1. Medications must be administered in accordance with the orders, including any required time frame. 2. Medications must be administered within one hour of their prescribed time, unless otherwise specified. 3. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff used proper hand hygiene during meal service and failed to ensure the kitchen ceiling was free from dust accumulation. The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's hygiene and sanitary practices policy, revised 2/16/24, showed: -Policy statement: Dining services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Policy implementation: Employees must wash their hands after personal body functions, after using tobacco, eating or drinking, whenever entering or re-entering the kitchen; [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow enhanced barrier precautions (EBPs) to prevent risks of infection for three of 20 sampled residents (Residents #29, #40, and #74) and failed to provide direct care following acceptable infection control procedures for another resident (Resident #39). This failure had the potential to affect all residents in the facility. The census was 123 with 99 residents in certified beds. Review of the facility's Enhanced Barrier Precautions policy, revised on 4/9/24, showed: -Enhanced barrier precautions are used as an infection prevention control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to complete neuro checks (neurological assessments) following unwitnessed falls or falls in which the resident hit their head, for two residents (Residents #44 and #35). The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's Neurological Evaluation policy, revised 5/25/21, showed: -Purpose: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition; -Steps in the procedure included: -Perform neurological checks with the frequency as ordered or per falls protocol; [...]
- 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 interview and record review, the facility failed to ensure the pharmacist reported any irregularities to the attending physician and the facility's Medical Director and Director of Nursing (DON), and failed to ensure these reports were acted upon for two residents (Residents #47 and #52). The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's Drug Regimen Review policy, provided as the facility's policy and procedure for the required monthly medication review for residents, revised February 2019, showed: -Policy Statement: It is the policy of the community that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. [...]
August 10, 2023Standard inspection · 4 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to label and date perishable and non-perishable food items in 1 of 2 walk-in refrigerators, 1 of 3 walk-in freezers, and 1 of 1 dry storage area. The facility also failed to label and date perishable items in the refrigerators and freezers in 2 out of 8 satellite unit kitchens.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview, record review, and facility policy review, it was determined that the facility failed to ensure the physician was notified of a change in condition for 1 (Resident #209) of 3 residents reviewed for change in condition. Specifically, the facility did not notify the physician when Resident #209 complained to staff of rectal bleeding.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to determine the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for two of 10 sampled employees hired since the last survey. The facility hired at least 300 new employees since the last survey. The census was 164. Review of the facility's Abuse/Neglect Prevention and Response Policy, dated 7/29/21, showed the following: -Policy Statement: Residents and client of the facility campuses and programs will live and be served in an environment that promotes dignity, respect and strived to be free from abuse, neglect and exploitation. Allegation of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency(ies), the resident protected and the allegation investigated; -Screening: [...]
- 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 wroteBased on interview, record review, and facility policy review, it was determined that the facility failed to provide the required bed hold notification at the time of transfer for 2 (Resident #209 and #219) of 3 residents reviewed for hospitalization.
September 13, 2019Standard inspection · 0 citations
Fire safety inspections
12 fire safety citations on file: 5 on November 7, 2024, 3 on August 10, 2023, 4 on September 13, 2019.
Every fire safety citation12 citations
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 10, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 10, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 13, 2019 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 13, 2019 · Corrected (the home has a date of correction)
- E
Meet requirements for the use of electrical equipment.
K 919 · September 13, 2019 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 13, 2019 · Corrected (the home has a date of correction)