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 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
32D
12E
1F
Potential for minimal harm
0A
0B
0C
July 17, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure a resident was free from staff coercion and harassment for 1 of 2 residents (Resident #1), in the survey sample.
October 12, 2023Complaint inspection · 4 citations
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, staff interview, facility documentation review, the facility staff failed to inform the Resident and the resident's representative of the administration of expired insulin for 1 of 3 residents (Resident #2) in the survey sample.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interviews, clinical record review, and facility document review, the facility staff failed to provide routine wound care treatments for 1 of 3 residents (Resident #1) in the survey sample.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident interview, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a Resident was administered the correct insulin for 1 of 3 residents (Resident #1) in the survey sample.
- 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 the facility's medication storage review of 1 medication cart and 1 medication room; the facility staff failed to ensure expired insulin was discarded after the use by date (28 days) and that they predated 2 vials of insulin before use.
October 28, 2021Standard inspection · 11 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on information gleamed during a complaint investigation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure clinical information and physician orders from specialty provider visits were incorporated to achieve continuity of care for 1 of 23 residents (Resident #9), in the survey sample.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, resident interview, staff interviews and clinical record review, the facility staff failed to provide necessary care and services to prevent development of pressure injuries for 2 of 23 residents (Resident #8), in the survey sample.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteThe facility staff failed to ensure one resident (Resident #6) in the survey sample of twenty four residents was allowed the opportunity to formulate an Advance Directive.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a medical record review, facility document review and staff interviews the facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day of 1/14/21 for one of 24 residents in the survey sample, Resident #20.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteThe facility staff failed to provide one resident (Resident #22) in the survey sample of twenty four residents with a Bed Hold Policy upon discharge to the hospital.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to monitor daily weights and Blood Sugar checks per physician's orders for 1 of 24 residents (Resident #15), in the survey sample.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to monitor one resident after sustaining an injury after falling by obtaining neurological checks. For 1 of 24 residents (Resident #16), in the survey sample.
- 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, staff interview, and clinical record review, the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications such as pressure ulcer development while utilizing an indwelling catheter for 1 of 32 residents (Resident #8), in the survey sample.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteThe facility staff failed to ensure ongoing communication and collaboration with the dialysis facility for one resident (Resident #6) in the survey sample of twenty four residents.
- 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 the facility's medication storage review of 1 medication cart and 1 medication room; the facility staff failed to ensure two opened containers of eye drops included the opened date.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, staff interview and facility documentation review the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents by not removing debris from two storage shed fires.
August 22, 2019Standard inspection · 18 citations
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on a complaint investigation, staff interview, facility documentation review, and clinical record review, the facility staff failed notify 1 of 38 residents in the survey sample, Resident #202, Responsible Party of changes in condition.
- E
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteFacility staff failed to ensure the required documentation was sent upon transfer to the hospital for seven of 38 residents in the survey sample, Resident #12, #20, #48, #40, #34, #200 & #11.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to ensure residents received necessary activities of daily care to include; showers, shampoos, and finger nail care for 4 of 38 residents (Resident #149, #44, #5 and #48), in the survey sample.
- E
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 observations, staff interviews and facility document review the facility staff failed to ensure drugs were dated when opened in accordance with currently accepted professional principles on 2 out of 4 medication carts; and failed to remove 2 boxes of expired Influenza Vaccine from the refrigerator in the Medication Storage Room.
- E
Provide and implement an infection prevention and control program.
Inspectors wrote2. The facility failed to implement appropriate infection control practices after utilizing a shared blood glucose meter. Blood glucose meters are devices that measure blood glucose levels. A medication administration pass observation was conducted with Licensed Practical Nurse (LPN) #5 on 8/20/19 at 4:30 p.m. The nurse obtained Resident #24's blood glucose using a shared glucometer. After obtaining the reading the nurse put the glucometer back into the medication cart without cleaning or sanitizing it first. After the medication pass the observation was shared with the nurse. LPN #5 stated, We do know to clean it after use. LPN #5 was not observed removing the glucometer to clean it after the issue was identified. The glucometer was not observed being used on another resident. [...]
- 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, staff interview, clinical record review and facility document review, it was determined that facility staff failed to ensure a clean, comfortable and homelike environment for two of 38 residents in the survey sample, Resident #5 and #11.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on clinical record review and staff interviews the facility staff failed to encode a quarterly Minimum Data Set (MDS) assessment prior to 92 days after the previous Omnibus Budget Reconciliation Act (OBRA) MDS assessment for 1 of 38 residents (Resident #25), in the survey sample.
- 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 clinical record review, resident interview, and staff interviews, the facility staff failed to ensure the baseline care plan included preferences for activities of daily living which included showers and shampoos for 1 of 38 residents in the survey sample, Resident #149.
- 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 staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow the comprehensive care plan for one of 38 residents in the survey sample, and improperly transferred Resident #12, which resulted in a fall with no injury.
- 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 observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to review and revise the care plan for 3 of 38 residents in the survey sample, Residents #12, #39 & #22.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on a complaint investigation, staff interview, facility documentation review, and clinical record review, the facility staff failed adequately develop and implement a discharge plan for 1 of 38 residents (Resident #202) in the survey sample.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 38 residents (Resident #7) in the survey sample who were unable to carry out activities of daily living, received the necessary services to maintain toenail care.
- 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, facility document review, and clinical record review, it was determined that facility staff failed to ensure an environment free from accidents and/or hazards for two of 38 residents in the survey sample, Resident #12 and #39. For Resident #12, facility staff conducted an improper transfer resulting in a fall with no injury and the facility staff failed to ensure the call light was in reach to promote safety and prevent avoidable accidents for Resident #39.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interviews, and clinical record review the facility staff failed to investigate the cause and implement interventions to prevent dislodgement of a nephrostomy tube for of 1 of 38 residents in the survey sample (Resident #33). A nephrostomy tube is a catheter that's inserted through your skin and into your kidney. The tube helps to drain urine from your body. The drained urine is collected in a small bag located outside of your body (www.healthline.com)
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review it was determined that facility staff failed to transcribe a complete order for oxygen for one of 38 residents in the survey sample, Resident #12.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to provide pharmaceutical services to ensure insulin was available to meet the diabetic needs of 1 of 38 residents in the survey sample, Resident #24.
- D
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 clinical record review and staff interviews the facility staff failed to ensure that Resident #6 did not receive as needed Xanax for greater than 14 days without the physician and/or prescribing practitioner evaluating the resident for the appropriateness of continuous as needed use for 1 of 38 residents in the survey sample.
- D
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 documentation review, the facility staff failed to store and prepare foods in a sanitary manner.
May 17, 2018Standard inspection · 12 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to ensure one resident (Resident #36), of 18 residents in the survey sample, remained free of accident hazard that resulted in a fall with fracture that resulted in harm of past non compliance.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to ensure the facility garbage/refuse container door remained closed when not in use. The Facility Staff Failed to ensure the outside facility garbage/refuse container door was closed when it was not in use.
- 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 observation, resident interview, staff interview, facility documentation review, clinical record review, the facility failed to notify the State Long Term Care Ombudsman of transfers to the hospital for 5 of 18 Residents in the survey sample (Resident #36, #30, #8, #31, and #33).
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wrote3. The facility staff failed to notify Resident #8 or his representative of the facilities bed hold policy when the resident was discharged to the hospital. Resident # 8 was re- admitted to the facility on [DATE] with diagnoses of seizures, cerebral palsy, chronic contractures, hypertension, severe intellectual disabilities and comfort measures. Resident #8 was sent out to the hospital emergency room on 1/16/18. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Pattern as having memory problems. In the area of Cognitive Skills for daily decision making as severely impaired. A revised Care Plan dated 12/6/17 indicated: Focus: Resident #8 has impaired cognition communication and/or impaired thought processes. Intervention- Introduce self frequently, add validation, visual cues, and gestures. [...]
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, staff interview and facility, documentation review, clinical recorded review, the facility staff failed for one (Resident #33) of 18 residents in the survey sample, to ensure non-pharmacological interventions were attempted prior to administering a psychoactive medication. For Resident #33, the facility staff failed to ensure non-pharmacological interventions were attempted prior to the administration of a as needed psychoactive medication (*Xanax). *Xanax is used to treat anxiety and panic disorders (https://www.drugs.com).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interview and facility documentation the facility staff failed to ensure that 1 of 18 residents (Resident #16) in the survey sample received a complete and accurate assessment.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 18 residents (Resident #31) in the survey sample who were unable to carry out activities of daily living receives the necessary services to maintain toenail care. The facility staff failed to ensure that podiatry services was provided to Resident #31.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure an oxygen concentrator filter was free of dust and debris for 1 resident of 18 in the survey sample (Resident #20) The following observations were made of the Resident in her room while oxygen was in use by nasal cannula at 2 liters per minute. 5/15/18 at approximately 12:10 PM during intial tour: oxygen concentrator filter dusty; 5/16/18 at approximately 3:30 PM observed oxygen concentrator filter dusty; 5/17/18 Observation at approximately 2:08 PM oxygen filter dusty. Interview with Unit Manager (UM) LPN #12 was conducted on 5/17/18 at approximately 2:10 PM. LPN #12 was asked to come look at filter in the Resident's room, with surveyor. After she observed the oxygen filter the surveyor asked her what she saw. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to communicate an ongoing assessment for one of 18 residents (Resident #33) for monitoring of complications before and after dialysis treatment. The facility staff failed to communicate an ongoing assessment with the dialysis center who attended an outpatient dialysis three days per week every Tuesday, Thursday and Saturday.
- 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 general observation of the nursing facility, staff interviews, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles in 1 out of 3 facility medication carts. The facility staff failed to ensure two *Lantus (insulin) pens were dated when open and one unopened Lantus pen was dated when placed on the medication cart. *Lantus (insulin glargine) is a man-made form of a hormone that is produced in the body. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin glargine is long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours. Storing opened (in use) Lantus: Store the injection pen at room temperature (do not refrigerate) and use within 28 days (www.drugs.com/lantus.html).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to ensure accurate medical records for 1 Resident of 18 in the survey sample. (Resident #36). The Facility Staff Failed to ensure Resident #36's April and May 2018 Treatment Administration Record was complete and accurate.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility failed to ensure infection control measures for sanitizing the glucometer prior and after use to prevent the potential transmission of infection for 1 Resident of 18 (Resident #4) was performed.
Fire safety inspections
29 fire safety citations on file: 9 on October 28, 2021, 5 on August 22, 2019, 15 on May 17, 2018.
Every fire safety citation29 citations
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 28, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 28, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 28, 2021 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 28, 2021 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 28, 2021 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 28, 2021 · Corrected (the home has a date of correction)
- D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · October 28, 2021 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · October 28, 2021 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · October 28, 2021 · 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 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 22, 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 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · August 22, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 22, 2019 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 17, 2018 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 17, 2018 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · May 17, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · May 17, 2018 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for sheltering.
E 22 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · May 17, 2018 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · May 17, 2018 · Corrected (the home has a date of correction)