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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
2E
6F
Potential for minimal harm
0A
0B
1C
July 2, 2024Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 73 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 73.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, taste test and pureed/mechanical soft guidelines review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect four residents (#1, #22, #46, and #58) who were prescribed pureed diets of 73 residents who consumed meals from the facility's kitchen. The facility census was 73.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, observation, and interview the facility failed to ensure call lights were within reach of Residents #37 and #176. This affected two residents (#37 and #176) of 73 residents residing at the facility.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #29's code status was accurately reflected in both the hard medical chart and the electronic medical record. This affected one resident (#29) of 73 residents reviewed for advanced directives. The facility census was 73.
- D
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 wroteBased on observation and interview, the facility failed to ensure Insulin KwikPens and insulin vials were dated when opened. This affected three residents (#3, #7, and #226) of twelve residents who were identified by the facility as receiving insulin. The facility census was 73.
June 4, 2024Complaint 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 record reviews, review of three self-reported incidents (SRIs) and interviews the facility failed to ensure Resident #52 was free from physical abuse by Resident #54. This affected one resident (Resident #52) of five residents reviewed for abuse. The census was 76.
November 13, 2023Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of safety data sheets, review of job descriptions, and review of facility policy, the facility failed to ensure corrosive toilet cleaning products were securely stored on the memory care unit. This affected one resident (Resident #50) of three residents reviewed for accident hazards and had the potential to affect the 11 other residents (#1, #18, #19, #38, #40, #44, #46, #47, #54, #68, and #70) the facility identified as being independently ambulatory, cognitively impaired, and resided on the memory care unit. The facility census was 73.
April 22, 2022Standard inspection · 16 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 76 residents currently residing in the facility.
- F
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 wroteBased on observation, interview and review of facility policy the facility failed to date and store opened medications properly and failed to dispose of expired medications. This had the potential to affect all 76 residents residing in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate use of personal protective equipment (PPE) for one resident (Resident #278) on Transmission Based Precautions (TBP), failed to enusre reusable non-critical care equipment was disinfected after each resident use, and failed to ensure linens for residents on TBP were processed appropriately in the laundry area. This had the potential to affect all residents residing in the facility. The facility census was 76.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on staff interview and record review, the facility failed to ensure a resident received notice of discharge in a timely manner. This affected one resident ( Resident #20) of one resident reviewed for discharge from facility. The facility also failed to ensure written notice of hospital transfers including the reason for the transfer were given to the resident or their representative and were provided to the long term care (LTC) Ombudsman in a timely manner. This affected three residents (#30, #33, and #50) of three residents reviewed for hospitalization. The facility census was 76.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview, record review and review of the facility policy, the facility failed to ensure advance directives (level of medical interventions a resident wishes to have performed in the event they experience an absence of a heartbeat or breathing) were located in the medical record. This affected two (Residents #32 and #66) of two residents reviewed for advanced directives. The facility census was 76.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report suspicion of abuse to the State agency within the required time frame. This affected two residents (#5, and #15) of four residents reviewed regarding submitted Self-Reported Incidents (SRIs). Facility census was 76.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of a facility Self-Reported Incident (SRI) and investigation, and staff interview, the facility failed to thoroughly investigate an allegation of sexual abuse for two residents (Residents #5 and #15). This affected two residents (Resident's #5 and #15) out of four residents reviewed for abuse. The facility census was 76.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on record review and staff interview, the facility failed to obtain an order for dialysis upon admission for one (#279) out of one resident reviewed for dialysis services. The facility identified two current residents who received dialysis services. The facility census was 76.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure care planned interventions were implemented to prevent one resident (Resident #7) from obtaining the code and entering a secured area on the nursing unit she resided on. This affected one resident (Resident #7) out of three residents reviewed for supervision. The facility census was 76.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to implement care planned interventions to ensure one resident's (Resident #46) incontinence care was completed timely. This affected one resident (Resident #46) out of three residents reviewed for incontinence care. The facility census was 76.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, record review and review of the facility policy the facility failed to implement care planned interventions to timely identify a significant weight loss for Resident #75 and notify the dietitian. This affected one resident (Resident #75) out of one resident reviewed for weight loss. The facility census was 76.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate supervision was provided Residents #5 and #15, and failed to ensure staff were knoweldgable regarding how to approach Resident #46 to ensure timely provision of incontinence care. This affected three of 25 residents residing on the secured dementia unit. The facility census was 76.
- 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 record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that the pharmacist's drug reviews were reviewed and what, if any, action was taken to address the recommendations. This affected two residents (#25 and #33) of five residents (#25, #30, #31, #33, and #44) reviewed for unnecessary medications. The facility census was 76.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure Resident #279 received medication per physician's order upon returning from dialysis. This affected one (Resident #279) of one resident reviewed for dialysis. The facility identified two current residents receiving dialysis. The facility census was 76.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observations and staff interviews, the facility failed to ensure call lights were in good repair and accessible to the resident. This affected one resident (#49) of one resident reviewed for physical environment. Facility census was 76.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and staff interview the facility failed to ensure daily posted nursing staff information was posted and timely updated. This had the potential to affect all 76 residents residing in the facility.
March 7, 2019Standard inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, the facility failed to appropriately store, label and date bread items and frozen items in the reach in freezer. This had the potential to affect 63 residents in the facility who receive food from the kitchen. The facility identified one resident, Resident #267, who was ordered nothing by mouth. The facility census was 64.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interviews, the facility failed to keep the trash dumpster area free from debris. This had the potential to affect all of the 64 residents residing in the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for Residents #19, Resident #33, and Resident #41. This affected three of 17 residents reviewed for accurate MDS assessments.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review and interview, the facility failed to administer medications with an error rate of 5% or less. This affected Resident #20 and Resident #28, two of six residents observed receiving medications. There were two errors out of 26 opportunities resulting in an error rate of 7.69%.
Fire safety inspections
21 fire safety citations on file: 4 on July 2, 2024, 10 on April 22, 2022, 7 on March 7, 2019.
Every fire safety citation21 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 2, 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 · July 2, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 2, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 2, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 22, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 22, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of flammable curtains.
K 751 · April 22, 2022 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 7, 2019 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 7, 2019 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 7, 2019 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 7, 2019 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 7, 2019 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 7, 2019 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 7, 2019 · Corrected (the home has a date of correction)