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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
27D
7E
1F
Potential for minimal harm
0A
0B
0C
December 2, 2021Standard inspection · 14 citations
- E
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 resident interview, staff interviews, and clinical record review, the facility staff failed to develop and implement a comprehensive person-centered care plan to address the preference of the resident for staff not to pull on her arms/shoulders which introduced pain during bed mobility and transfers for 1 of 45 residents (Resident #39), in the survey sample.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to ensure 1 of 45 residents (Resident #74) in the survey sample were free of significant medication error.
- 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 observation and staff interviews the facility staff failed to ensure medications were labeled and stored in accordance with currently accepted professional principles in 1 out of 4 facility medication carts and 1 out of 2 medication refrigerators. The facility staff failed to ensure one Lantus insulin pen and antibiotic eye drop (Neo/poly ointment) were dated once opened. The facility staff failed to ensure a multi-dose vial of PPD vaccine was dated once opened.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on resident interviews, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide evidence that two out of 45 residents were invited to attend a care plan meeting, Resident #47 and Resident #120, in the survey sample.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on resident interview, staff interviews, and clinical record review, the facility staff failed to accommodate the preference of the resident to have showers prior to 6:00 p.m., for 1 of 45 residents (Resident #39), in the survey sample.
- 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 wrote3. The facility staff failed to provide Resident #61 the opportunity to formulate an Advance Directive. Resident #61 was re- admitted to the facility on [DATE]. Diagnoses for this resident included kidney failure, epilepsy and idiopathic neuropathy. Resident #61 was assessed as having a BIMS score of 13. A Care Plan dated 10/05/21 indicated this resident Focus- was at risk for unresolved pain and multiple medical problems. Goals- Interventions- Assess for side effects of pain medication. observe for constipation: new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. During an interview on 12/02/21 at 12:36 PM with the Assistant Director of Nursing (ADON) she was asked if Resident #61 or his Representative had been offered the opportunity to formulate an Advance Directive. The ADON stated, not to her knowledge. 4. [...]
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #7 and Resident #98) in the survey sample.
- D
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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 45 residents (Resident #45 and 106) in the survey sample.
- 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 wroteBased on staff interview and clinical record review, the facility staff failed to offer a bed hold for 1 of 45 Residents, Resident #45.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to complete the required discharge Minimum Data Set (MDS) assessment within the required timeframe after a planned discharge from the facility for 1of 45 residents (Resident #2), 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 the one resident (Resident #93's) Dialysis communication book was updated timely during Dialysis treatments in a survey sample of 43 residents.
- 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 interviews, and review of the facility's policy, the facility staff failed to store food under sanitary conditions.
- 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, staff interview and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 45 residents (Resident #74) in the survey sample.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, resident interview, staff interview and review of facility documents, the facility's staff failed to have the call bell accessible and functional for resident's use. For 1 of 45 residents (Resident #47), in the survey sample.
October 11, 2018Standard inspection · 12 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, staff interviews, medical record review and facility documents the facility staff failed to provide for the accommodation of needs to maintain independence and to ensure the safety for 1 of 40 residents in the survey sample, Resident #154. For Resident #154, he facility staff failed to ensure the call bell was placed within reach.
- D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on observations, staff and resident interviews, clinical record review and facility documentation review, the facility staff failed to notify one of 40 residents (Resident #19) of a change in roommate. The facility staff failed to inform Resident #19 in advance, of a roommate change of a resident that was transferred to his room from another unit in the facility.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a complaint investigation, record review, family interviews, staff interviews, and facility document review the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to discharge for 1 of 40 residents in the survey sample, Resident #148. The facility staff failed to issue a Medicare Notice of Non-Coverage prior to Resident #148's discharge that was facility planned on 8/8/17 however occurred on 8/9/17.
- D
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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 40 residents (Resident #63) in the survey sample. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #63's transfer to the emergency room (ER) from dialysis on 07/18/18.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interview, and facility documentation review, the facility staff failed to ensure one (Resident #146) of 40 residents in the survey sample had an accurate Minimum Data Set (MDS) assessment. Resident #146's discharge MDS, dated [DATE], was coded that she was discharged to the hospital rather than discharged home.
- 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 a complaint investigation, record review, family interviews, staff interviews, and facility documentation review, the facility failed to develop a Comprehensive Care Plan to include discharge goals and interventions for 1 of 40 residents in the survey sample, Resident #148. The facility staff failed to develop a Comprehensive Care Plan to include discharge goals and interventions for Resident #148
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on a complaint investigation, record review, family interviews, staff interviews, and facility document review the facility failed to involve the resident and resident representative in the final discharge plan for 1 of 40 residents in the survey sample, Resident #148. The facility staff failed to ensure that Resident #148's son was involved in the final discharge plan scheduled on 8/8/17.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interviews, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for two resident in the survey sample of 40 (Resident #61 and 63) who were unable to independently carry out activities of daily living (ADL's). 1. The facility staff failed to ensure Resident #61 received showers according to resident plan and preference. 2. The facility staff failed to ensure Resident #63 received showers according to resident plan and preference.
- 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, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to receives the appropriate care and services to prevent potential indwelling catheter complications for 1 of 40 residents (Resident #48), in the survey sample. The facility staff failed to anchor Resident #48's indwelling urinary catheter to prevent tension on the catheter and avoid potential kinking of the tubing.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure 2 of 40 residents (Resident #53 and #63) received the care and services consistent with the standards of practice and comprehensive person-centered care plan. 1. The facility staff failed to ensure hemodialysis care was provided for Resident #53 to include consistent and accurate assessments of *bruit and *thrill by the licensed nurses. 2. The facility staff failed to ensure hemodialysis care was provided to Resident #63 to include consistent assessments of bruit and thrill, as well as communication between the facility and dialysis center.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the licensed nursing staff were competent with the appropriate skills to provide assessments of Arterio-Venous (AV) dialysis shunts for 2 of 40 residents (#53 and #63) in the survey sample. 1. The facility staff failed to ensure the licensed nursing staff were competent in the provision of hemodialysis care for Resident #53 to include accurate assessments of *bruit and *thrill. 2. The facility staff failed to ensure the licensed nursing staff were competent in the provision of hemodialysis care for Resident #63 to include accurate assessments of bruit and thrill.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, clinical record review and review of facility documentation, the facility staff failed to ensure hand washing after removal of gloves during accuchecks (a fingerstick for blood glucose testing) for 2 of 40 residents (Resident #53 and #13) in the survey sample. 1. The facility staff failed to ensure hand washing after the removal of gloves during the accucheck procedure for Resident #53. 2. The facility staff failed to ensure hand washing after the removal of gloves during the accucheck procedure for Resident #13.
March 23, 2017Standard inspection · 11 citations
- K
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Inspectors wroteBased on observations, staff interviews, clinical record review, and facility document review the facility staff failed to provide an environment that was free of hazards to prevent accidents for 13 of 47 residents in the survey sample, Resident's #12, #18, #19, #20, #21, #25, #26, #27, #28, #29, #30, #31, and #32 resulting in the identification of Immediate Jeopardy. The facility staff failed to ensure safe coffee temperatures on 6/23/16 to prevent an avoidable accident for Resident #18 resulting in second degree abdominal burns after spilling hot coffee on self, and on 3/22/17 during this survey coffee served to Resident's #12, #19, #20, #21, #25, #26, #27, #28, #29, #30, #31, and #32 during the lunchtime meal in all four dining rooms was identified at temperatures sufficient to cause tissue injury and third degree burns resulting in the identification of Immediate Jeopardy.
- G
Provide necessary care and services to maintain or improve the highest well being of each resident .
Inspectors wroteBased on observations, staff interviews, clinical record review, and facility document review the facility staff failed to provide the necessary care and services for a 2nd degree abdominal burn in a timely manner to maintain the highest practicable physical wellbeing for 1 of 47 resident in the survey sample, Resident #18. The facility staff failed to properly assess, and follow Physician orders to obtain a Wound Consult following a 2nd degree abdominal burn from a hot coffee spill on 6/23/16 resulting in a 7 day delay in treatment for Resident #18, which constitutes harm.
- F
Store, cook, and serve food in a safe and clean way.
Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to store and prepare foods in a sanitary manner. The facility staff failed to ensure an open 25 pound bag of panko (bread crumbs) was stored in a sealed container to prevent physical contaminants from inadvertently entering the food, failed to ensure an open date and use by dated was placed on a 35 ounce open bag of toasted oats, and failed to ensure two deep fryer baskets were free from cross-contamination that were in contact with a trash can.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteThe facility failed to provide medically related social services for 1 out of 15 residents as evidenced by the facility choosing not to follow the wishes of the legal power of attorney (POA) but following the wishes of the non-POA for her mother's diet.
- E
Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
Inspectors wroteBased on observation, resident interviews, staff interview, facility documentation review, the facility staff failed to maintain a clean comfortable homelike environment in 3 of 8 resident shower rooms. On 3/22/17 at approximately 10:00 to 11:00 a.m. during the General Observation tour of the facility the surveyor observed the following items: Soiled Shower rooms (3B, 2B, 2A) On 3/22/17 during the General Observation tour of the facility from 10:00 to 11:00 a.m. 3B Resident Shower Room was observed soiled. Used towels were observed lying in the shower room. The Shower room bench was observed with torn rough edges on the padded seat. On 3/22/17 during the General Observation tour of the facility from 10:00 to 11:00 a.m. 2B shower room was observed to be soiled. A used towel was observed lying in the shower room. The shower room bench was observed with torn rough edges. [...]
- E
Have a program that investigates, controls and keeps infection from spreading.
Inspectors wroteBased on observation, staff interviews, and facility document review the facility staff failed to ensure that a single use wound care product was discarded after resident use for 1 of 47 residents in the survey sample, Resident #3, and failed to prevent the potential for the transmission of infection with the storage of clean supplies. 1. The facility staff failed to ensure that a single use Calcium Alginate Wound care product was discarded after wound care was completed on Resident #3. 2. The facility staff failed to ensure the storage of clean supplies in a manner to prevent the potential for transmission of infection.
- E
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to ensure continuing competency of nursing aides with training hours no less than 12 hours a year. Specifically, the facility staff failed to ensure that five out of 46 CNAs (Certified Nursing Assistants) had completed at least 12 hours of training per year per hire anniversary date for each CNA.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteThe facility staff failed to notify the physician and or designee and the Power of Attorney of a change in physical, mental, or psychosocial status for 1 of 15 residents in the survey sample, Resident #115. The facility staff failed to notify the physician and or designee and the Power of Attorney that Resident #115 was not receiving the dietary supplement (Pure Aloe Force) as ordered by the physician and the resident was refusing the anti-platelet medication Aggrenox. Aggrenox is used to reduce the risk of stroke in people who have had blood clots or a mini-stroke.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, resident, staff and group interviews, the facility staff failed to provide laundry services with reasonable accommodations for one resident, Resident #17, in the survey sample of 47 residents.
- D
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure the safe storage and transportation of oxygen cylinders. On 3/22/17 at approximately 10:10 a.m., during the General Observation Tour with the Assistant Administrator and the Director of Maintenance one full small oxygen cylinder was observed in the oxygen storage room, stored standing on boxes of supplies and not secured in a rack to prevent the cylinder from the potential of becoming airborne if it were to fall. The Oxygen Storage Room was observed not being directly beside or across from a resident room. During the observation of the oxygen cylinder, the Maintenance Director placed the one cylinder into the storage rack for oxygen cylinders. [...]
- D
Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Inspectors wroteBased on observation, staff interview, facility documentation review, the facility staff failed to ensure that all staff were trained in emergency procedures, specifically use of a fire extinguisher. On 3/22/17 at approximately 11:20 a.m. a Certified Nursing Assistant (CNA) was questioned on use of a fire extinguisher. The CNA #1 stated that to use a fire extinguisher she would take the extinguisher out of the wall unit, then squeeze the handle and aim at the bottom of the fire. When CNA #1 was asked what she would do if nothing came out of the nozzle when she squeezed the handle, she had no response. When CNA #1 was asked what she would do if she was not able to squeeze that handle, CNA had no response. The CNA and surveyor were standing in front of an extinguisher while questions were asked. Answers to PULL THE PIN were written on the extinguisher. [...]
Fire safety inspections
10 fire safety citations on file: 2 on December 2, 2021, 4 on October 11, 2018, 4 on March 23, 2017.
Every fire safety citation10 citations
- D
Have an enclosure around a vertical opening shaft.
K 311 · December 2, 2021 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · December 2, 2021 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · October 11, 2018 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 300 · October 11, 2018 · 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 · October 11, 2018 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 11, 2018 · 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 23, 2017 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 23, 2017 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 23, 2017 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 23, 2017 · Corrected (the home has a date of correction)