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
0G
0H
0I
Potential for more than minimal harm
20D
5E
6F
Potential for minimal harm
0A
0B
1C
November 7, 2024Standard inspection, Complaint inspection · 9 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness.
- 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 wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to store and label biologicals adequately when staff failed to date four insulin (medications used to treat high blood glucose levels) pens when opened and failed to remove or dispose of four expired bottles of stock medications. This deficient practice placed Residents (R)9, R27, R71, and R228 at risk of receiving expired, ineffective insulin and other residents at risk of receiving expired ineffective stock medications.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment in one of three dining rooms. This placed the residents who ate in the main dining room at risk for impaired health and well-being.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents with two residents reviewed for transfers. Based on record review and interviews, the facility failed to provide written notification within a practicable timeframe of a facility-initiated transfer to Resident (R) 25 and R6. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for R25 and R6. This deficient practice placed the residents at risk of uninformed care choices and impaired rights.
- 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 wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)26 and R6 with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility and in the same room.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents with two residents reviewed for pressure ulcers (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review the facility failed to initiate interventions to mitigate risks for the development of pressure ulcers for Resident (R) 128, who developed two facility-aquired pressure injuries. This deficient practice placed R128 at risk for further pressure-related injury and related complications.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to provide an environment free from accident hazards when staff failed to use the Hoyer lift (full body mechanical lift) to facilitate a safe transfer for Resident (R) 130 whose admission note indicated she required a Hoyer lift for transfers. This deficient practice placed R130 at risk for falls and potential injury.
- 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 wroteThe facility had a census of 74 residents. The sample included 18 residents with one reviewed for urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review the facility failed to provide adequate catheter care and services within the standards of care for Resident (R) 130. This deficient practice placed R130 at risk for urinary tract infection and other catheter-related complications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to adhere to infection control for Enhanced Barrier Precautions (EBP -an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and gloves used during high contact resident care activities) for Resident (R)26, who had a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart)line in her right upper arm, and R130 who had a urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). This placed the residents at increased risk for infection.
April 16, 2024Complaint inspection · 2 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 84 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteThe facility reported a census of 84 residents with one resident reviewed for therapeutic diet. Based on observation, interview, and record review, the facility failed to follow the menu for Resident (R)3 to provide the physician ordered gluten free diet.
November 20, 2023Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 99 residents with four residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform proper hand hygiene between resident contacts while delivering meal trays and failure to don appropriate personal protective equipment (PPE - equipment worn by personnel to minimize exposure hazards that can lead to injuries or illnesses) when delivering meals to a resident under isolation precautions (a combination of appropriate PPE and hand hygiene practices to prevent the spread of infectious agents between individuals). This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility.
January 5, 2023Standard inspection · 8 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteThe facility reported a census of 100 residents. Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week by not having a registered nurse scheduled as required.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 100 residents. The facility reported all residents received meals prepared in the kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and in sanitary conditions due to the staff's failure to date and cover cooked food items, failure to perform hand hygiene, and the failure to handle ready-to-eat sandwich foods including ham, turkey cheese and bread. under sanitary conditions, to prevent the spread of food borne illnesses to the residents of the facility.
- 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 wroteThe facility reported a census of 100 residents with 20 residents selected for review that included three residents sampled for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based on observation, interview, and record review, the facility failed to provide sanitary placement of Resident (R)15 and R47's urinary catheter collection bags. This had the potential to cause urinary tract infections (UTI) and injury from accidental removal of the catheter.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility reported a census of 100 residents, with 20 included in the sample, including one resident sampled for respiratory services. Based on observation, interview and record review, the facility failed to provide necessary respiratory care and services on one Resident (R) 41's, who required physician ordered oxygen.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteThe facility reported a census of 100 residents with 20 residents sampled. Based on observations, interview and record review, the facility failed to follow physicians' orders for one Resident (R)81, of the six residents reviewed for unnecessary medications.
- 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 wroteThe facility reported a census of 100, with 20 residents in the sample, that included six residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to ensure the consultant pharmacist identified the use of a as needed (PRN) Ativan (antianxiety) medication with a stop date for Resident (R) 8, one of the six residents reviewed.
- 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 wroteThe facility reported a census of 100, with 20 residents in the sample, that included six residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to obtain an end date for the use of as needed (PRN) Ativan (antianxiety) medication for one Resident (R) 8, of the six residents reviewed.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteThe facility census totaled 100 residents with 20 residents included in the sample, that included one resident sampled for therapeutic diets. Based on observation, interview and record review, the facility failed to ensure Resident (R) 41 received the therapeutic diet of a limited concentrated sweets (LCS)/Consistent Carbohydrate diet, as ordered by the physician.
February 4, 2021Standard inspection · 12 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility had a census of 87 residents. Based on observation, interview, and record review the facility failed to ensure facility staff utilized appropriate infection control principles when Dietary Staff failed to perform hand hygiene between meal tray deliveries to multiple resident rooms, and failed to ensure residents followed social distancing protocols while eating in the dining room during a time of COVID-19 (highly contagious respiratory illness that caused the recent pandemic).
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteThe facility census totaled 87 residents, with four residents with orders to receive a fortified diet (added fats and protein to increase calories and nutrients) for additional nutrition. Based on observation, interview, and record review the facility failed to serve fortified diets to four residents with fortified diet orders.
- E
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteThe facility census totaled 87 residents with 13 residents the facility identified as on a physician's prescribed therapeutic diet. Based on observation, interview, and record review the facility failed to serve therapeutic diets (diet to treat a medical condition, such as diabetes) to 13 residents as ordered by the physician.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility reported a census of 87 residents. The facility had one main kitchen where all food was prepared to serve to residents. The facility failed to prepare and store food in a sanitary manner by failure of dietary staff to wear gloves when handling ready to eat foods and failed to ensure the hairnet covered all hair, the storage of unmarked and outdated foods, failed to cover room trays when they were removed from the delivery cart, failed to perform hand hygiene between tray deliveries to residents, and failed to ensure residents were socially distanced when eating in the dining room.
- 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 wroteThe facility had a census of 87 residents with 18 sampled, including two regarding grievances. Based on observation, interview, and record review, the facility failed to assist Resident (R) 43 with filling out a grievance form and failed to inform R82 of the grievance policy and procedure.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility census totaled 87 with 18 included in the sample. Based on observations, interview, and record review the facility failed to provide nail care for Resident (R)70.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteThe facility reported a census of 87 residents, with 18 sampled, including two for vision/ hearing. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 82 received proper treatment and assistive devices to maintain vision by not assisting with adequate eyeglasses.
- 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 wroteThe facility census totaled 87 residents with 18 residents in the sample, and one sampled for Catheter/Urinary Tract Infection (UTI). Based on observation, interview and record review the facility failed to provide appropriate care of Resident (R)81's catheter bag when draining urine to ensure infection control measures where appropriately followed.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility identified a census of 87 with 18 residents included in the sample and three residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to provide the care planned supervision at meals to Resident (R) 69, a resident identified by the facility as at risk for significant weight loss, to encourage nutritional intake.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility census totaled 87 residents with 18 residents included in the sample, and two reviewed for oxygen use. Based on observation, interview, and record review the facility failed to ensure appropriate physician orders for oxygen use including care and maintenance of oxygen tubing and bubbler for Resident (R)81 and failed to ensure staff practiced appropriate infection control principles regarding oxygen tubing when staff placed oxygen tubing, that had been on the floor, on the resident without changing the oxygen tubing.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility reported a census of 87 residents with five reviewed for unnecessary medications. Based on interview and record review the facility failed to adequately monitor the results of blood sugar checks for two residents who received insulin (a hormone that regulates blood sugar) injections, Resident (R) 43 and R82 .
- C
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteThe facility census totaled 87. Based on interview and record review the facility failed to ensure residents received mail in a timely manner, which included mail delivery on Saturdays.
Fire safety inspections
51 fire safety citations on file: 20 on November 7, 2024, 3 on July 31, 2024, 16 on January 5, 2023, 12 on February 4, 2021.
Every fire safety citation51 citations
- L
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · November 7, 2024 · Corrected (the home has a date of correction)
- L
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)
- L
Conform to length requirements for dead end corridors.
K 251 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Establish procedures for tracking staff and patients during an emergency.
E 18 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · November 7, 2024 · Corrected (the home has a date of correction)
- F
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)
- 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
Provide properly protected cooking facilities.
K 324 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · 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
Install corridor and hallway doors that block smoke.
K 363 · 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
Have properly installed electrical wiring and gas equipment.
K 511 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · November 7, 2024 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 7, 2024 · Corrected (the home has a date of correction)
- F
Establish an Emergency Preparedness Program (EP).
E 1 · July 31, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 31, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · July 31, 2024 · Corrected (the home has a date of correction)
- F
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 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 300 · January 5, 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 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 5, 2023 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
K 771 · January 5, 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 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · January 5, 2023 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · January 5, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 5, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 5, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · January 5, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Have properly sized and located compartments to protect residents from smoke.
K 371 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 4, 2021 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · February 4, 2021 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · February 4, 2021 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 4, 2021 · Corrected (the home has a date of correction)