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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
1E
0F
Potential for minimal harm
0A
0B
0C
November 15, 2024Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on clinical record review and staff interview the facility staff failed to ensure a complete and accurate clinical record for 1 of 2 residents, Resident #1.
August 21, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to implement a comprehensive person-centered care plan for supervision to prevent falls for 1 of 7 sampled residents, Resident #4.
May 9, 2024Standard inspection · 1 citation
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure 2 of 36 residents were free of unnecessary medications, Residents #63 and #139.
December 5, 2022Standard inspection · 6 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 observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to discard an out of date food item, failed to label pre-poured beverages, and stacked wet pans together.
- 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 observation, Resident interview, staff interview, and family interview the facility staff failed to ensure a clean, comfortable, and home like environment for 2 of 34 residents, Resident #166 and Resident #141.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement written policies and procedures regarding the reporting of resident abuse within the specified timeframe of two (2) hours for 1 of 34 residents in the survey sample, Resident #56.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to report an incident of resident-to-resident abuse within two (2) hours of when the abuse was discovered for 1 of 34 residents in the survey sample, Resident #56.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide activities of daily living (ADL) care for a dependent resident, for 1 of 34 residents, Resident #10.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 34 residents, Resident #147.
January 30, 2020Standard inspection · 2 citations
- 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 clinical record review and staff interview, the facility staff failed to ensure the resident's right to formulate an advanced directive as evidenced by failure to enact a physician order in accordance with the advance directive for 1 of 35 residents in the survey sample (Resident #256).
- 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, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident medications were stored securely for 1 of 35 Residents (Resident #152) as evidenced by leaving medications at the bedside.
Fire safety inspections
13 fire safety citations on file: 2 on May 9, 2024, 11 on December 5, 2022.
Every fire safety citation13 citations
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 9, 2024 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 9, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 5, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · December 5, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 5, 2022 · Waiver
- E
Provide properly protected cooking facilities.
K 324 · December 5, 2022 · Waiver
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 5, 2022 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · December 5, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 5, 2022 · Corrected (the home has a date of correction)
- D
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 · December 5, 2022 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · December 5, 2022 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · December 5, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · December 5, 2022 · Corrected (the home has a date of correction)