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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
27D
2E
0F
Potential for minimal harm
0A
1B
0C
March 29, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff and resident interview, clinical record review, review of facility documents, the facility staff failed to administer physician ordered medications for 1 of 7 residents (Resident #1), in the survey sample.
September 22, 2022Standard 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 closed record review, complaint investigation, and family and staff interviews, the facility staff failed to ensure one resident (Resident #297), in the survey sample of 46 residents, was free from sexual assault which resulted in harm.
- G
Respond appropriately to all alleged violations.
Inspectors wroteBased on a closed record review, complaint investigation, family and staff interviews, the facility staff failed to preserve evidence following an incident of sexual abuse for one resident (Resident #297) in the survey sample of 46 residents.
- E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Inspectors wroteBased on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed to convey within 30 days after the resident's discharge from the facility the resident's funds, and a final accounting of those funds, to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interviews and clinical record review, the facility staff failed to follow professional standards of nursing practices for 1 out of 40 residents (Resident #51) in the survey sample.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to afford two residents (R#62 and R#38) in the survey sample the opportunity to participate in the care planning process.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed the facility staff failed to ensure the resident's personal funds which exceeded $100.00 were kept in an interest bearing account until it was distributed to the Resident and/or Representative for 1 of 21 residents (Resident #121), 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 wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure 2 of 40 residents in the survey sample, (Resident #32 and 81) were given 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 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 4 residents (Resident #39 and #64) in the survey sample.
- D
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 wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a care plan to include their goals when discharged and admitted to the hospital for 1 of 46 residents (Resident #50), 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 observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a notice to a representative of the Ombudsman office for 1 of 46 residents (Resident #77), 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 observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a copy of the facility's bed hold policy for 1 of 46 residents (Resident #50), in the survey sample.
- 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 and clinical record review, the facility staff failed to include anticoagulation in the comprehensive care plan, for 1 of 40 resident (Resident #32), in the survey sample.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to ensure a resident received the application of his right hand splint as ordered by the physician to prevent further decrease in range of motion for 1 of 40 residents, (Resident #35), in the survey sample.
- 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 observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure one resident did not receive PRN Psychoactive medications for more than 14 days for 1 of 46 residents (Resident #91), in the survey sample.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on resident interviews, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 46 residents (Resident #38) in the survey sample received the services needed to meet their dental needs.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on a revisit survey conducted 11/15/22 through 11/17/22 to the standard survey that was conducted on 09/18/22 through 09/22/22, the facility staff failed to correct identified quality deficiencies.
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on observation, staff interview and facility documentation, the facility staff failed to designate at least one qualified staff member as the facility's Infection Preventionist (IP).
October 18, 2019Standard inspection · 7 citations
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on a 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 for 2 of 39 residents in the survey sample, Resident # 238 and Resident #239.
- 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 staff interview, facility document review, and clinical record review, it was determined that facility staff failed to develop a baseline care plan for one of 39 residents in the survey sample, Resident #288.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and review of the facility's Medication Administration Record (MAR), the facility failed to administer medications as ordered for 1 of 39 residents in the survey sample, Resident #52.
- 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 document review and clinical record review, it was determined that facility staff failed to obtain an order for the use of a Foley catheter for one of 39 residents in the survey sample, Resident #55.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview and clinical record review it was determined that facility staff failed to administer oxygen per physician's order for one of 39 residents in the survey sample, Resident #291.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and review of the facility's Medication Administration Record (MAR), the facility failed to ensure 1 of 39 residents in the survey sample was free from unnecessary medication, Resident #52.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on the facility's Missing Assessment Report, facility document review and staff interviews the facility staff failed to ensure that Discharge Assessments were completed and transmitted timely for 3 of 39 residents in the survey sample, Resident #3, Resident #4 and Resident #5.
May 25, 2018Standard inspection · 7 citations
- D
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 staff interview, closed record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed for one (Resident #379) of 34 residents in the survey sample to notify the responsible party of a fall.
- 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, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 resident (#8) in the survey sample of 34 residents. Facility staff failed to maintain an accurate person centered care plan related to transfer needs for Resident #8.
- 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 interviews, clinical document and facility documentation review the facility staff failed to maintain proper infection control practices for indwelling Foley catheter maintenance for 2 residents (#23) and (#129) in the survey sample of 34 residents. 1. The facility staff failed to ensure Resident #23's indwelling Foley catheter urine collection bag was not in contact with the floor. 2. The facility staff failed to ensure Resident #129's indwelling catheter bedside drainage bag was emptied and prevented from making contact with the floor.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review the facility staff failed to ensure non-pharmacological measures were offered prior to the administration of analgesic medications. The facility staff failed to ensure non-pharmacological measures were offered prior to the administration of analgesic medications for one Resident (Resident # 11) of 34 residents in the survey sample.
- 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 observation, resident interview, staff interview, facility documentation review, clinical record review facility staff failed to ensure 2 residents (Resident #7 and #52) were free from unnecessary psychotropic medications. 1. The facility staff failed to ensure Resident #7's as needed Trazodone was reassessed and extended for another 14 days. 2. The facility staff failed to ensure Resident #52 received gradual dose reductions in an effort to decrease and/or discontinue psychotropic drugs use.
- 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 and stored in accordance with currently accepted professional principles in 1 out of 8 facility medication carts. The facility staff failed to ensure one *Humalog (insulin) vial was dated once open and one Humalog vial was removed from medication cart once expired. *Humalog is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood (https://www.drugs.com/humalog.html). On [DATE] at approximately 12:25 p.m., this surveyor inspected the medication cart on Unit 2 (Front Hall) with LPN #1. During the inspection of the insulin stored inside the medication cart; [...]
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on staff interview, clinical record review, and review of the Hospice policy; the facility staff failed to ensure the Hospice Agency provided a written agreement describing the provision of services for 1 of 34 residents (Resident #129), in the survey sample. The facility staff failed to ensure the Hospice Agency provided the facility staff with the coordinated plan of care for Resident #129, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency.
Fire safety inspections
19 fire safety citations on file: 10 on September 22, 2022, 9 on May 25, 2018.
Every fire safety citation19 citations
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 22, 2022 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 22, 2022 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Conduct risk assessment and an All-Hazards approach.
E 6 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Create arrangements with other facilities to receive patients.
E 25 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · September 22, 2022 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · September 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 25, 2018 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · May 25, 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 · May 25, 2018 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · May 25, 2018 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · May 25, 2018 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · May 25, 2018 · Corrected (the home has a date of correction)
- C
Establish policies and procedures for volunteers.
E 24 · May 25, 2018 · Corrected (the home has a date of correction)
- C
Establish roles under a Waiver declared by secretary.
E 26 · May 25, 2018 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · May 25, 2018 · Corrected (the home has a date of correction)