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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
0E
0F
Potential for minimal harm
0A
0B
0C
May 27, 2021Standard inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interviews, record review, and review of [NAME] and [NAME], Fundamentals of Nursing, the facility failed to ensure: A licensed staff washed her hands and changed gloves after removing the soiled dressing from the wound before cleaning the wound for Resident Identifier (RI) #119. This affected RI #119, one of three opportunities of wound care observation. Findings Include: A review of [NAME] and [NAME] Fundamentals of Nursing ninth edition, chapter 48, page 1225 revealed . Implementation 1. Perform hand hygiene. Open sterile packages and topical solution containers as necessary. 2. Remove bed linen and patient's gown as necessary to expose ulcer and surrounding skin. Keep remaining parts covered and apply clean gloves. 3. Clean ulcer thoroughly with normal saline or cleaning agent. 4. Remove gloves perform hand hygiene and apply clean or sterile gloves. 5. [...]
- 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, interviews, record review, and review of facility policy titled Perineal Care the facility failed to ensure: 1) Certified Nursing Assistant (CNA) used soap while cleaning perineal area for Resident Identifier (RI) #97 during incontinent care 2) CNA changed gloves after removing soiled brief and cleaning resident's perineal area and before applying clean brief. This affected one of one resident observed during incontinent care. Findings Include: A review of a facility policy titled Perineal Care with an effective date of 12/19/07 revealed . Purpose . The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections . Infection Control Protocol and Safety 1) Wash your hands thoroughly with soap and water at the following intervals as indicated: a) Before the procedure . c) Anytime they become soiled with . body fluids . [...]
March 12, 2020Standard inspection · 2 citations
- D
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, record review, review of the 2017 U.S. (United States) Public Health Service Food Code, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) washed hands when filling water pitchers with ice for Resident Identifier (RI) #s 35 and 100; and 2) CNAs did not touch food and utensils with bare hands when assisting RI #125 and RI #74 with meal set-up and/or feeding. These findings affected four of 157 total residents residing in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure a Licensed Nurse did not use gloves that were placed on top of the vanity sink in Resident Identifier (RI) #39's room to administer RI #39's oral medication inhaler. Further, the Licensed nurse did not wash or sanitize her hands prior to putting on another pair of gloves. This affected one of four residents and one of three Licensed Nurses observed during medication administration pass.
February 7, 2019Standard inspection · 3 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, interview, and review of the facility policy titled Self Administration of Medication, the facility failed to ensure an order was in place in accordance with facility policy specifying Resident Identifier (RI) #31 could self-administer medication before a Licensed Practical Nurse (LPN) left medication at RI #31's bedside to be administered at a later time. This affected one of eight residents observed for medication administration.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, record review, interviews, and review of Potter and [NAME] Fundamentals of Nursing, Ninth Edition, the facility failed to ensure Resident Identifier (RI) #71's intravenous (IV) access site was dated/timed and initialed. This affected one of two residents in the facility with IVs.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and review of a facility policy titled Hand washing, the facility failed to ensure a Licensed Practical Nurse (LPN) did not use her bare, wet hands to turn the water faucet off, after washing her hands, then return to the medication cart to continue medication administration. This was observed with one of three nurses observed during medication administration.
Fire safety inspections
6 fire safety citations on file: 1 on May 27, 2021, 4 on March 12, 2020, 1 on February 7, 2019.
Every fire safety citation6 citations
- E
Install corridor and hallway doors that block smoke.
K 363 · May 27, 2021 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 12, 2020 · 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 12, 2020 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · March 12, 2020 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 12, 2020 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 7, 2019 · Corrected (the home has a date of correction)