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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
5E
2F
Potential for minimal harm
0A
0B
0C
March 16, 2023Standard inspection · 12 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 facility policy review, observation, and interview, the facility failed to maintain clean and sanitary equipment for 1 of 3 ice machines and 2 of 2 stove drip pans. The facility also failed to properly store refrigerated foods in 1 of 2 walk-in coolers.
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on facility policy, medical record review, and interview the facility failed to determine and perform a significant change Minimum Data Set (MDS) assessment for 1 of 40 sampled residents (Resident #16) reviewed.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to create and provide a baseline care plan for 5 of 40 (Residents #59, #62, #100, #216, and #358) sampled residents reviewed for baseline care plans.
- 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 facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care plan conference meetings with the resident or resident's representative for 11 out of 40 sampled residents (Residents #19, #30, #32, #49, #57, #60, #69, #76, #77, #81, and #82).
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on medical record review and interview, the facility failed to develop and implement an effective discharge planning process for 1 of 40 sampled residents (Resident #32) reviewed for potential discharge.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure 1 of 5 sampled residents (Resident #77's) enteral tube was labeled and dated.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to apply hubs to the end of an IJ (Internal Jugular Vein) Catheter external limbs and failed to apply a hub on the end of an IV (Intravenous) tubing and date the tubing for 1 of 17 (Resident #216) residents.
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on facility record review and interview the facility failed to obtain State approval to open a Long Term Care (LTC) Hemodialysis Unit.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to have a declination form for Influenza and Pneumococcal Immunizations for 1 of 5 (Resident #8) sampled residents reviewed.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on medical record review and interview the facility failed to have a declination form for the COVID-19 vaccination for 1 of 5 (Resident #8) sampled residents reviewed.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to have 1 of 40 operable call lights.
- D
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to have adequate dining space for 3 of 3 rooms in the facility.
April 24, 2019Standard inspection · 3 citations
- 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 facility policy review, medical record review and interview, the facility failed to revise and update a care plan for 1 resident (#46) of 52 residents reviewed.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on medical record review, observation and interview, the facility failed to follow physician orders to provide total assistance with meals for 1 resident (#46) of 52 residents reviewed.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on facility policy review, medical record review and interview, the facility failed to maintain an accurate and complete record for 1 resident (#18) of 52 residents reviewed related to the Physician Orders and Physician Orders For Life Sustaining Treatment/Physician Orders for Scope of Treatment (POLST/POST) form not matching.
April 11, 2018Standard inspection · 15 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 review of the dish machine manufacturer's recommendation, review of the manual washing protocol, and interview, the facility dietary department failed to operate the dish machine per the manufacturer's recommended temperature range, failed to sanitize items appropriately in the 3 compartment sink, and failed to maintain dietary equipment in a sanitary manner in 1 of 6 observations in the dietary department.
- E
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 facility policy review, medical record review and interview, the facility failed to obtain completed advanced directives for 8 of 31 sampled residents (Resident #90, Resident #91, Resident #98, Resident #99, Resident #590, Resident #28, Resident #83 and Resident #86) reviewed for advanced directives.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteMedical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses of Nondisplaced Fracture of Right Acetabulum, Fracture of Right Ischium, Muscle Weakness, Difficulty in Walking, Fracture of Shaft of Left Humerus, Fracture of Left Shoulder Girdle, Wedge Compression Fracture of T9-T10 Vertebra, Moderate Laceration of Left Kidney, Fracture of Lower End of Right Ulna, Fracture of Right Patella, Fracture of Right Radial Styloid Process, Moderate Laceration of Spleen, and Multiple Fractures of Ribs, Right Side. Medical record review of Resident #90's Order Summary Report dated 4/1/18-4/30/18 revealed wound care treatment orders to his left shoulder, right hip surgical site and right flank. Continued review revealed the resident received scheduled and PRN (as needed) pain medications. [...]
- E
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 facility policy review, medical record review and interview, the facility failed to ensure as needed (PRN) psychotropic medications had a 14 day limitation or a prescriber documentation with medical rationale for continuation for 5 of 12 sampled residents (Resident #60, Resident #21, Resident #35, Resident #36, Resident #82) and failed to conduct behavior monitoring for 2 of 12residents (Resident #82, Resident #86) reviewed.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation and interview, the facility dietary department staff failed to ensure the resident meals were served per the menu, failed to obtain food preferences, and failed to honor resident food preferences for 6 of 86 residents receiving meals.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to honor and/or obtain food preferences for 6 of 86 sampled residents (Resident #25, Resident #73, Resident #91, Resident #98, Resident #342) receiving a meal.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse within the 2-hour time frame as required to the State Agency for 2 residents of 7 sampled residents (Resident #82 and Resident #83) reviewed for abuse.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview, the facility failed to accurately assess the Minimum Data Set (MDS) for 1 of 44 sampled residents (Resident #60) reviewed for MDS accuracy.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review, observation and interview, the facility failed to provide wound care treatments as ordered for 1of 44 sampled residents (Resident #98) reviewed.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on review of the facility policy, medical record review, observation, and interview, the facility failed to administer the enteral feeding per the Physician's Order for 2 of 10 sampled residents (Resident #28, Resident #36) reviewed with enteral feedings.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to administer pain medication in a timely manner as ordered for 3 of 44 sampled residents (Resident #90, Resident #342, and Resident #99) reviewed.
- 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 facility policy review, medical record review, document review and interview, the facility failed to conduct a drug regimen review for 1 of 8 sampled residents (Resident #60) reviewed.
- 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 facility policy review, observation, and interview, the facility failed to properly store a medication in 1 of 3 medication rooms, failed to maintain current refrigeration temperature logs in 2 of 4 medication rooms, and failed to ensure 1 of 1 treatment cart and 1 of 7 medication carts were locked when not in use by staff.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview, the facility failed to maintain accurate and complete medical records for 2 of 44 sampled residents (Resident #28 and Resident #36) reviewed.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, the facility dietary department failed to maintain the slicer in a safe operating condition.
Fire safety inspections
24 fire safety citations on file: 14 on March 16, 2023, 6 on April 24, 2019, 4 on April 11, 2018.
Every fire safety citation24 citations
- F
Have an enclosure around a vertical opening shaft.
K 311 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · March 16, 2023 · 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 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Provide large enough exits.
K 231 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of portable space heaters.
K 781 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 16, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · April 24, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 24, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2019 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 24, 2019 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 24, 2019 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 24, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 11, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 11, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 11, 2018 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · April 11, 2018 · Corrected (the home has a date of correction)