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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
14D
3E
0F
Potential for minimal harm
0A
0B
0C
April 18, 2024Standard inspection · 11 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two residents (#210 and #211), assisted with care by a Certified Nursing Assistant (CNA), was free from verbal/psychosocial abuse. out of twelve residents sampled for abuse.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure four dependent residents (#45, #43, #69, and #72) were provided with activities out of ten residents sampled. Findings Include: Multiple observations were made on 4/15/2024 at 10:00 a.m., 1:00 p.m., and 4:00 p.m., showing Resident #45 laying down in his bed dressed in a red shirt and newspapers spread out all over his bed. Resident # 45 was not able to communicate his needs. During an observation made on 04/16/204 at 10:30 a.m., and at 3:00 p.m., and on 4/17/2024 at 11:00 a.m. Resident #45 was observed laying down in his bed, dressed in the same red shirt for 3 days in a row. The same newspapers were observed for 3 days spread out all over his bed. Resident # 45 was not able to communicate his needs. [...]
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observation, record review, and interviews, and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a relicensure and complaint survey that was conducted on 4/15 - 4/18/24 and was cited at F880. On 6/11/24 a revisit survey was conducted, and the facility was recited at F880. The facility had developed a Plan of Correction with a completion date of 5/18/22. During the revisit survey the facility failed to 1. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure an effective infection control program was implemented related to 1) the use of personal protective equipment (PPE) for two of three designated transmission based precaution (TBP) rooms, 2) no hand hygiene provided to residents prior to meals for four of four hallways, and 3) the Infection Preventionist (IP) conducting appropriate surveillance for influenza.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews and record review, the facility 1) failed to provide access to quality care related to a dignified meal service for three residents (# 69, #43, and #89) out of 13 residents reviewed for dining, and 2) failed to ensure a catheter was stored in a privacy bag for one resident (#43) out of 29 sampled residents.
- D
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 wroteBased on observations, record review, and interviews, the facility failed to ensure a grievance was filed related to a resident's room changed for one resident (#87), out of eight residents sampled. Findings Include: During an observation made on 04/15/2024 at 10:45 AM., Resident #87 was observed laying down in her bed with her call light within reach. The Resident said she would like to have a room change because she doesn't get along with her roommate. She said she spoke to the Social Services Assistant multiple times about wanting to move to another room, but nothing has been done about it. During an observation made on 04/16/2024 at 12:00 PM., Resident #87 was observed sitting up in her wheelchair with a blanket placed over her lap. She stated she and her roommate got into a verbal fight last night and she really wants her room to change. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to report an allegation of verbal/psychosocial abuse for two residents (#210 and #211) out of twelve residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews, record review, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to one resident (#45) out of ten residents sampled. Finding Include: On 4/15/2024 at 10:30 AM., Resident #45 was observed laying down in his bed dressed in a red shirt and newspapers spread out all over his bed. Resident #45 was not able to communicate his needs. On 04/16/204 and 4/17/2024, at 11:00 AM., Resident #45 was observed laying down in his bed, dressed in the same red shirt for 3 days in a row. The same newspapers were observed for 3 days spread out all over his bed. Resident #45 was not able to communicate his needs. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper orders and documentation were in the medical record for two residents (#10 and #255) out of twenty-nine sampled residents.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, interviews and record review, the facility did not ensure foot care was provided when needed for one resident (#69) out of one residents sampled.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews and record reviews, the facility did not accommodate dietary preferences related to alternate meal requests for four residents (#351, #18, #352, and #86) out of 13 sampled residents.
November 5, 2021Standard inspection · 2 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident #250) of twenty residents receiving respiratory (nebulizer) medication was assessed and monitored for self-administration of a respiratory nebulizer treatment.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure a clean and sanitary living environment was provided during three (11/02/21, 11/03/21 and 11/04/21) of four days observed, and for two (#39 and #84) of two residents in room [ROOM NUMBER].
February 14, 2020Standard inspection · 5 citations
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, interview and record review the facility failed to conduct a comprehensive, accurate assessment for one (#20) of 50 sampled residents related to skin conditions which included discolorations.
- 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 wroteBased on observation, interview and record review the facility failed to review and revise the Comprehensive Patient Centered Care Plan related to smoking based on the resident's assessment for one (#19) of three sampled residents of 15 total smokers.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident record review, staff and resident interview and facility policy review, it was determined the facility failed to ensure that three residents (#7, #13 and #62) of 15 residents who smoke were free from smoking hazards.
- 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 wroteBased on observation, interview and record review the facility failed to monitor for behaviors, effects and side effects related to psychotropic medications for one resident (#5) of five sampled residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control practices related to adequately cleaning blood glucose meters for two residents (#7 and #99) of two residents observed for glucose monitoring.
Fire safety inspections
9 fire safety citations on file: 7 on April 18, 2024, 1 on November 5, 2021, 1 on February 14, 2020.
Every fire safety citation9 citations
- D
Conduct testing and exercise requirements.
E 39 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 18, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 18, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 5, 2021 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 14, 2020 · Corrected (the home has a date of correction)