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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
18D
3E
1F
Potential for minimal harm
0A
0B
0C
July 20, 2023Standard inspection · 3 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 observation, staff interview, and facility policy review, the facility staff failed to properly store, label and date food items, and clean the floors within the facility's main kitchen. This failure had the potential to affect all 51 residents who consumed food prepared from the facility's kitchen.
- 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, record review, and review of facility policy, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions related to pain for one (Resident (R) 6) of two sampled residents reviewed for pain in a total sample of 20. This failure placed the resident at risk of unmet care needs and a diminished quality of life.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, record review, and review of the Recreational Therapy Director's job description, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences as identified in the resident assessment for two (Residents (R)39 and R27) of four residents reviewed for activities in a total sample of 20. This failure placed the residents at risk of a diminished quality of life.
March 3, 2022Standard inspection · 3 citations
- D
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observation, and staff interview, the facility staff failed to provide required postings, including a list of names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible and understandable for the resident population for one of three buildings ([NAME] 2).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to continue skilled care services following the issuance of a SNF ABN (skilled nursing facility advance beneficiary notice), when the Resident's representative selected to continue services and they would pay for them, for one Resident (Resident #15) in a sample of 3 Residents selected for review of ABN notices.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on Observation, staff interview, clinical record review, and facility document review, the facility staff failed to perform handwashing, and gloving during medication pour and pass observations to prevent the spread of infection, for two Residents (Resident #31, and #19) in a survey sample of 15 residents observed receiving medications.
July 11, 2019Standard inspection · 17 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to prevent Resident #19 from abusing one resident (Resident #148) in a sample of 21 residents. This is harm.
- E
Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review the facility staff failed to provide a qualified activities director for one of three units.
- E
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, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for four residents (Resident #97, Resident #27, Resident #31, Resident #297) in a sample size of 21 residents.
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to have quarterly QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance/Performance Improvement) meetings for 3 of a possible 4 quarters
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to maintain dignity for one resident (Resident #97) in a sample size of 21 residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure safety and clinical appropriateness for self-administration of medication for 1 resident (Resident #297) in a survey sample of 21.
- 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 wroteBased on staff interview, facility documentation review and clinical record review the facility staff failed to uphold a Resident's desire to formulate an Advance directive for one Resident (Resident #27) in a survey sample of 21 Residents.
- 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 staff interviews and clinical record review, the facility staff failed to notify the Resident and Resident's representative of the reason for and location of transfer, and failed to notify the ombudsman for one Resident (Resident #14) in a survey sample of 21 Residents.
- 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a comprehensive care plan for one Resident (Resident #19) in a sample size of 21 residents.
- 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 documentation review, and clinical record review the facility staff failed to develop a careplan to include the respiratory diagnosis and use of respiratory equipment for one Resident (Resident #31) in a survey sample of 21 Residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow professional practice standards for medication and treatment administration for three Residents (Residents #16 #97, and #297) in a survey sample of 21 Residents. The staff stated their professional standard for nursing was Mosby.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide an activity program for two Residents (Resident #27, Resident #97) in a survey sample of 21 Residents.
- 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, and staff interview, the facility staff failed to mitigate an accident hazard for 1 (Resident #297) of 21 sampled residents.
- 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, facility documentation review, and clinical record review, the facility staff failed to provide appropriate treatment and services for 1 resident (Resident #39) with a clinically-justified indwelling urinary catheter in a survey sample of 21 residents.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on staff interview, facility documentation review and clinical record review the facility staff failed to ensure one Resident, Resident #27, was served the correct therapeutic diet in a survey sample of 21 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 observation, staff interview, and facility documentation review, the facility staff failed to ensure that a multi dose vial of TB (tuberculosis) Test medication was dated after being accessed via needle puncture for 1 of 2 sampled units and failed to safely secure an Albuterol inhaler for 1 of 21 sampled residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to maintain respiratory equipment in a manner to prevent infections for one Resident (Resident #31) in a survey sample of 21 Residents.
Fire safety inspections
12 fire safety citations on file: 2 on March 3, 2022, 10 on July 11, 2019.
Every fire safety citation12 citations
- 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 · March 3, 2022 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · March 3, 2022 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · July 11, 2019 · 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 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Provide large enough exits.
K 231 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 11, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 11, 2019 · Corrected (the home has a date of correction)