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
3D
0E
4F
Potential for minimal harm
0A
0B
0C
September 12, 2024Standard inspection · 3 citations
- F
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, interview, and record review the facility failed to ensure a multi-dose vial was labeled when opened and failed to ensure controlled medications were double locked. This has the potential to affect all residents in the facility.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to store frozen items off the floor. This failure has the potential to affect all residents in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review the facility failed to have a Legionella (bacteria) prevention and mitigation program in place. The facility also failed to implement enhanced barrier protections (EBP) for a resident with an indwelling catheter. These failures have the potential to affect all residents in the facility.
August 15, 2023Standard inspection · 3 citations
- 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 interview and record review the facility failed to have a PRN (as needed) psychotropic medication stop date to 1 of 5 residents (R59) reviewed for unnecessary medications in the sample of 5.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to wash hands after providing pericare to prevent the spread of infection to 1 of 5 residents (R58) reviewed for infection control in the sample of 5.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to offer the pneumococcal conjugate vaccines (PCV20) or the pneumococcal polysaccharide vaccine (PPSV23) for 1 of 5 residents (R58) reviewed for vaccinations in the sample of 5.
September 14, 2022Standard inspection · 1 citation
- F
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff wore N95 face masks when testing residents for COVID-19. This applies to all residents residing in the facility.
Fire safety inspections
17 fire safety citations on file: 7 on September 12, 2024, 6 on August 15, 2023, 4 on September 14, 2022.
Every fire safety citation17 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Have proper power supply for life support equipment.
K 915 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · September 12, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 12, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · September 12, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · August 15, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 15, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 15, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 15, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 15, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 15, 2023 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · September 14, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 14, 2022 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · September 14, 2022 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 14, 2022 · Corrected (the home has a date of correction)