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 12 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
2E
3F
Potential for minimal harm
0A
0B
0C
October 17, 2019Standard inspection · 2 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, interviews, review of the 2017 Food Code, and a facility policy titled, Tray Line and Meal Service Temperatures, dietary staff failed to ensure: 1) the temperatures of food items on the tray line were checked prior to service; 2) thermometers were accurately calibrated prior to use; 3) staff did not handle ready-to-eat food with bare hands; 4) staff washed their hands prior to the application of gloves; and 5) food found to be below recommended temperatures, was reheated to 165 degrees Fahrenheit (F) prior to service. These deficient practices had the potential to affect 87 residents for whom meals were prepared and served at the time of this survey. According to the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the census at the time of the survey was 90. Findings Include: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review and review of the Assure Platinum Glucometer Study Guide, the facility failed to ensure a medication nurse, Employee Identifier (EI) #1, wore gloves while performing a finger stick blood glucose test on Resident Identifier (RI) #61 on 10/16/19, during the evening medication pass observation. Findings Include: Review of an undated Assure Platinum Glucometer Study Guide, revealed the following: BLOOD GLUCOSE TESTING Obtaining a Drop of Blood Note . We advise healthcare professionals to wear gloves during blood testing . RI #61 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus. RI #61's Order Summary Report for 10/2019, revealed RI #61 was to receive blood glucose testing before meals and at bedtime. On 10/16/19 at 3:50 p.m., the surveyor observed EI #1 gather supplies to check RI #61's blood sugar. [...]
September 6, 2018Standard 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 observations, interviews, review of the 2017 U.S. (United States) Public Health Service Food Code and review of facility policies titled Dry Storage, Dietary Food Handling and Water Temperature for Dishwashing Machines, the facility failed to ensure: (1) dented cans were not stored with other canned goods; (2) an opened jar of jelly had a use by date on it; (3) a container of barbeque sauce did not have sauce on the outside of the container; (4) the tips of the thermometers were not touching the bottom of the glass and the thermometer was not submerged under water during calibration; (5) a cook did not place the handle of the tong on top of a pan of rolls after she touched the handle with her bare hands; (6) grease was not on top of the oven; (7) dust like particles were not on the back of the oven fan and on a book above the toaster; (8) plate warmers and covers were air dried; [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #55's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/20/18, reflected RI #55 was receiving Dialysis services. This deficient practice affected RI #55, one of 40 residents whose MDS assessments were reviewed. Findings Include: RI #55 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses to include End Stage Renal Disease and Dependence on Renal Dialysis. A review of RI #55's Quarterly MDS assessment, with an ARD of 08/20/18, did not identify RI #55 as having received Dialysis services during this assessment period. A review of RI #55's September 2018 Physician Orders documented: . Dialysis @ (at) (name of Dialysis center) Tues (Tuesday)/Thur (Thursday)/Sat (Saturday) . [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure a care plan was developed for RI (Resident Indentifier) #241, a resident who required the use of Oxygen (O2). This deficient practice affected RI #241, one of three sampled residents who required the use of O2.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and review of PERRY & [NAME], 9th Edition, Clinical Nursing Skills & Techniques, the facility failed to ensure Resident Identifier (RI) #3's nebulizer face mask and reservoir cup were rinsed and dried after receiving a nebulizer treatment from a Licensed Practical Nurse (LPN). This affected 1 of 1 resident observed receiving a nebulizer treatment and 1 of 6 nurses observed during medication administration pass. Findings Include: A review of PERRY & [NAME] 9th Edition, Clinical Nursing Skills & Techniques, Chapter 21, Page 564, documented .When medication is completely nebulized .Rinse nebulizer cup .Dry completely .Proper storage reduces transfer of microorganisms . RI #3 was admitted to the facility on [DATE]. RI #3's Order Review Report for September 2018 documented a diagnosis of Pnuemonitis Due To Inhalation Of Food and Vomit. [...]
August 17, 2017Standard inspection · 6 citations
- F
Store, cook, and serve food in a safe and clean way.
Inspectors wroteBased on observation, interview, and review of the facility policy titled Refrigerated Storage, the facility failed to ensure raw beef shoulder, raw pork tenderloin, and open sandwich meat were not stored in the same container in the walk-in cooler, creating the potential for cross-contamination. This had the potential to affect 89 of 92 residents in the facility, identified by the facility as receiving meals from the dietary department.
- E
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure: 1) the residents and/or their representatives were informed of the risks and benefits related to the use of side rails prior to installation; and 2) Resident Identifier (RI) #8 did not have a full side rail up on the room/exit side of the bed on 08/15/2017 and a fall mat was placed at the bedside. These failures affected RI #s 1, 2, 3, 8, 10, and 11, six of six residents reviewed for side rail use, and had the potential to affect all 57 of 92 residents residing in the facility, identified by the facility as using side rails.
- E
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility
Inspectors wroteBased on record review, interviews, and review of the job description for the [NAME] President of Quality Management and Clinical Services, corporate staff failed to ensure a policy was developed and/or the facility procedure was revised for side rail use. This had the potential to affect all 57 of 92 residents in the facility, identified as utilizing side rails.
- D
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interviews, the facility failed to ensure individualized care plan approaches were developed to address Resident Identifier (RI) #2's need for 3/4 (three quarter) side rails up times two. This affected one of 17 residents for whom care plans were reviewed.
- D
Allow residents the right to participate in the planning or revision of care and treatment.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure Resident Identifier (RI) #8's Care Guide was updated to reflect the need for 3/4 (three quarter) side rails up times two per the resident assessment. This affected one of 17 residents for whom care plans were reviewed.
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #8's interventions of 3/4 (three quarter) side rails up times two and a fall mat at bedside were implemented. This affected one of six residents sampled for falls and side rails and one of 17 residents for whom care plans were reviewed.
Fire safety inspections
8 fire safety citations on file: 4 on October 17, 2019, 3 on September 6, 2018, 1 on August 17, 2017.
Every fire safety citation8 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 17, 2019 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · October 17, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · October 17, 2019 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 17, 2019 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 6, 2018 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 6, 2018 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · September 6, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 17, 2017 · Corrected (the home has a date of correction)