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 22 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
16D
3E
1F
Potential for minimal harm
0A
0B
0C
November 7, 2024Standard inspection · 7 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection in two of three units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; and, -Ensure glucometers were cleaned in a sanitary manner.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews, the facility failed to take steps to prevent abuse for three (#40, #10 and #35) of three residents reviewed for abuse out of 29 sample residents. Specifically, the facility failed to protect Resident #40, Resident #10 and Resident #35 from physical abuse.
- 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 observations, record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for one (#110) of one resident out of 29 sample residents. Specifically, the facility failed to develop and implement within 48 hours of admission a person-centered baseline care plan for Resident #110 that included pertinent healthcare information, specifically related to the resident's hard cervical collar and fractured left wrist, necessary to properly care for the resident.
- 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 record review and interviews, the facility failed to develop a comprehensive care plan for services that were provided in order to attain the resident's highest practicable physical, mental and psychological well-being and to provide effective and person-centered care for one (#40) of one resident out of 29 sample residents. Specifically, the facility failed to ensure Resident #40 had a care plan for the use of an anticoagulant medication.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#110) of one resident out of 29 sample residents received treatment and care in accordance with professional standards of practice. Specifically, for Resident #110, the facility failed to: -Obtain physician's orders which indicated if it was acceptable to remove the resident's hard cervical (neck) collar brace for skin checks and showers; -Obtain physician's orders for the weight bearing status of the resident's fractured left wrist; -Follow up on scheduling the resident's neurosurgeon/orthopedic doctor's appointment and CT (computed tomography) scan appointment; and, -Ensure nursing staff were aware of and informed of pertinent healthcare information related to the resident's hard cervical collar and fractured left wrist.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received the proper treatment and assistive devices to maintain hearing and vision for two (#7 and #40) of two out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #7 received hearing aids and vision services in timely; and, -Ensure Resident #40 received timely vision services.
- 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 record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for one (#29) of five residents out of 29 sample residents. Specifically, the facility failed to ensure the pharmacist's monthly medication regimen review (MRR) recommendations and the associated physician's orders to discontinue baclofen and guaifenesin for Resident #8 were followed up on in a timely manner, which resulted in the resident receiving additional doses of the medications.
April 20, 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 observations, record reviews, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of foodborne illness in one of one kitchen. Specifically, the facility failed to ensure food holding temperatures were at appropriate levels to prevent the growth of foodborne pathogens.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure three (#37, #32 and #2) of five residents reviewed out of 29 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Ensure Resident #37 was provided with timely incontinence care; and, -Provide Resident #32 bathing was in accordance with their plan of care; and -Provide Resident #2 received assistance with oral care.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the environment for three (#53, #57 and #36) residents of eight residents reviewed for aciident/hazards out of 29 sample residents remained as free of accident hazards as possible and the residents received adequate supervision to prevent accidents. Specifically the facility failed to: -Ensure medications were not left at the bedside for Resident #53; -Ensure an registered nurse completed an assessment post resident fall for Resident #57 and #36; and, -Ensure Resident #57 did not eloped from the facility.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#19) resident out of 29 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to resolve to a grievance filed by a Resident #19 about her medication not being administered timely.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for one (#34) resident out of two residents reviewed for abuse out of 29 sample residents. Specifically, the facility failed to ensure effective person-centered interventions were in place to prevent physical abuse by Resident #31 toward Resident #34.
- 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 observations, record review and interviews the facility failed to comprehensively assess and care plan the continued use of a wheelchair lap tray for one (#36) out of 29 sample residents. Specifically, the facility failed to ensure Resident #36's lap tray was on the comprehensive care plan with a release schedule communicated to staff.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure two (#44 and #20) of 29 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to: -Investigate, determine origin and monitor a bruise to Resident #44's forearm; and, -Ensure a treatment for Resident #20 was administered according to physician orders and by a qualified staff member.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review, observations and interviews the facility failed to provide timely interventions to prevent worsening of a pressure injury for one (#28) of three residents of sampled 29 residents. Specifically, the facility failed to: -Measure and implement treatment orders for Resident #28's left heel pressure injury until five days after her admission; and, -Ensure preventative boots were ordered timely for Resident #28.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on resident observations, record review, and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#61 and #266) of seven residents reviewed for supplemental oxygen use out of 29 sample residents. Specifically, the facility failed to: -Obtain a physician's order for continuous oxygen use for Resident #61; and, -Administer oxygen by the physician's order for Resident #266.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#34) of five residents reviewed for dementia care out of 29 sample residents. Specifically, the facility failed to provide personalized interventions to address the Resident #34's behaviors, which caused a resident altercation.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on record review and interviews, the facility failed to promptly provide, or obtain dental services to meet the residents' needs for one (#53) of one resident out of 29 sample residents. Specifically the facility failed to ensure timely follow up for Resident #53's dentures.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to perform wound care in a hygienic manner.
January 6, 2022Standard inspection · 3 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development of pressure injuries for two (#38 and #14) of six residents reviewed for pressure injuries out of 24 sample residents. Resident #38, was admitted on [DATE] for a long term care due to traumatic brain injury and continuous care needs. The resident was admitted to the facility with no open areas to her sacrum as documented on initial skin assessment on 12/9/21. On 12/15/21 (six days later) resident developed stage 3 pressure injury to her sacrum. Upon admission, the facility identified Resident #38 was at risk for developing pressure injuries, however no interventions were put in place to prevent the development of pressure injury. [...]
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#39 and #14) of five residents reviewed for accidents out of 24 sample residents remained as free from accident hazards as possible. Resident #39 sustained three falls in the facility over a two-month period. The facility identified the resident's numerous fall risks (stroke affecting left non-dominant side, weakness with paralysis on the left side and history of falls) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize her risks and keep her safe from injury. The resident's care plan was not updated with new interventions and resident's needs after the fall on 10/24/21, 12/3/21, and 12/21/21. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review and interviews the facility failed to provide meal assistance for two of seven ( #37 and #43) residents reviewed out of 24 sample residents. Specifically, the facility failed to provide meal assistance to Resident #37 and #43. I. Facility policy The Activities of Daily Living policy, updated December 2017, was received from the nursing home administrator on 1/5/22 at 2:10 p.m. It read in pertinent part: Residents will be provided with care and services appropriate to maintain their ability to carry out activities of daily living. The residents who are unable to perform those activities independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. [...]
Fire safety inspections
23 fire safety citations on file: 10 on November 7, 2024, 6 on April 20, 2023, 7 on January 6, 2022.
Every fire safety citation23 citations
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 7, 2024 · 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 · November 7, 2024 · Waiver
- F
Install properly constructed and protected linen or trash chutes.
K 541 · November 7, 2024 · Waiver
- F
Have a properly installed medical gas master alarm panel.
K 904 · November 7, 2024 · Waiver
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 7, 2024 · Corrected (the home has a date of correction)
- E
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 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 20, 2023 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 20, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 20, 2023 · Corrected (the home has a date of correction)
- F
Have power receptacles that are properly grounded.
K 912 · April 20, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 20, 2023 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · April 20, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 6, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 6, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 6, 2022 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · January 6, 2022 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 6, 2022 · 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 · January 6, 2022 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · January 6, 2022 · Corrected (the home has a date of correction)