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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
39D
7E
1F
Potential for minimal harm
0A
0B
1C
June 30, 2026Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interviews and record review conducted during the abbreviated survey, the facility did not ensure residents received care consistent with professional standards of practice to prevent and promote healing of pressure ulcers for one of three residents (Resident # 4) reviewed for pressure ulcers. Specifically, Resident #4 had deep tissue injuries to both feet and heel booties, recommended by the wound care consultant on 10/29/2024, were not implemented until after 01/07/2025.
September 8, 2025Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on video surveillance, record review, and interviews conducted during the Abbreviated Survey (2595161), the facility did not ensure that residents were free from abuse, neglect, and mistreatment for 1(Resident #1) of 3 residents reviewed for abuse. Specifically, on 08/19/2025 at 11:55 PM, video surveillance reviewed revealed interaction between resident #1 and Licensed Practical Nurse #1. Resident #1 was seated in their wheelchair in the doorway of their room while Licensed Practical Nurse #1 was at the medication cart with their back turned to Resident #1. Licensed Practical Nurse #1 is seen turning around and began a verbal exchange with Resident #1. Licensed Practical Nurse #1 is seen moving behind Resident #1's wheelchair and attempt to hold Resident #1's hand down and force him back into their room. Resident #1 is seen resisting. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey (2595161), the facility did not ensure that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 1 of 3 residents reviewed (Resident #1). Specifically, on 08/19/2025 at 11:55 PM, video surveillance footage revealed Licensed Practical Nurse #1 engaged in a verbal interaction with Resident #1. Resident #1 and Licensed Practical Nurse #1 were using hand gestures during the interaction. Licensed Practical Nurse #1 moved behind the wheelchair and attempted to pull the resident back into their room. Resident #1 was seen resisting and Licensed Practical Nurse #1 continued to forcefully pull the resident while seated in the wheelchair, into their room. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey (2595161) the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, comprehensive care plan and the resident's choices for 1 (Resident #1) of 3 residents reviewed for pain. Specifically, Resident #1 had a Physician's order for Oxycodone HCL 5 mg orally every 6 hours as needed for pain. Resident #1 on 08/25/2025 revealed on 8/19/2025, they requested their pain medication from Licensed Practical Nurse #1 around 11:54pm because they were in pain. Resident #1 did not receive their pain medication. Resident #1 received their next dose of pain medication at 1:28AM on 08/20/2025, approximately eight hours and thirty-four minutes after the previous administration.
April 22, 2025Complaint inspection · 5 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (NY00331684, NY00334367), the facility did not ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal care for 2 of 3(Resident #5, #6) residents reviewed for activities of daily living. Specifically, (1) review of Resident #5's certified nurse assistant documentation for the months of January and February 2024 revealed bladder and bowel incontinence care was not provided by direct care staff on 19 occasions out of 31days. Further review of the January 2024 and February 2024 certified nurse assistant documentation revealed areas of care including showers, personal hygiene and assistance during meals were not consistently signed as being provided by direct care staff; [...]
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on record review and interview during an abbreviated survey (NY00334367, NY00331640) the facility did not ensure that sufficient nursing staff was consistent for residents according to the Facility Assessment. Nursing and certified nurse assistant staff levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the facility daily staffing sheets for January 2024 and February 2024 revealed staffing was not adequate across various shifts based on the unit needs and (Provider Average Ratio)PAR levels documented in the facility assessment.
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00334367), the facility did not ensure residents were free from significant medication error for 4 (Residents #17, #20, #24, #34) out of 42 residents reviewed for medication. Specifically, on 2/25/2024 there was no nurse on the second floor to administer medications to the residents during the 7 AM to 3 PM shift. 36 out of the 42 residents on the unit did not receive their medication with 30 of the residents having significant medications. Significant Medications that were not administered included: Antihypertensives, Retroviral, Anti-seizure, Anti-depressants, Antidiabetics, Insulin, Narcotics, Anticoagulants, Antibiotics, Immunosuppressants, Anti-Parkinsonism and Anti-psychotics.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review and interviews conducted during the Abbreviated Survey (NY00360526), the facility did not ensure 1(Resident #1) of 3 residents reviewed for quality of care received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, 1.) Resident #1 who had a stage 2 pressure ulcer that was resolved on 10/29/24 and reopened on 1/28/25, was not being turned and positioned prior to 1/28/25 as per the certified nurse aide documentation. Furthermore, the Wound Care Doctor gave instructions on 1/28/25 to turn and reposition the resident every 1-2 hours while in bed and every 30 minutes while in chair, and the certified nurse aide documentation revealed that it was not being done.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00331684), the facility did not ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight for 1 out of 3 residents (Resident #5) reviewed for nutrition. Specifically, Resident #5 had a weight loss of fifteen percent in thirty days. Review of Resident #5's certified nurse documentation revealed direct care staff were not consistently documenting the resident's intake and there were several occasions when the resident did not consume or only consumed twenty five percent of their meal. There was no documented evidence of nursing or administration being informed of Resident #5's poor intake.
April 15, 2025Complaint inspection · 6 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00352230, NY00331567), the facility did not ensure the report of the results of an investigation was submitted to the New York State Department of Health in accordance with State law within 5 working days of the incident for 3 out of 3 residents (Resident #2, Resident #3, Resident #4) reviewed for abuse. Specifically, (1) On 8/22/2024, Resident #2 was witnessed by Certified Nurse Aide #1, hitting Resident #3 on the back of the head with a flexi-bar (rubber cylinder used for therapy). Review of the 5-day investigative conclusion submission revealed it was not submitted to the New York State Department of Health until 8/28/2024; [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00353705, NY00352230, NY00332692), the facility did not ensure that an allegation of abuse was thoroughly investigated for 6 (Resident #1, #2, #3, #38, #39, #40) of 6 residents reviewed. Specifically, (1) on 9/8/2024 Resident #1 reported to Licensed Practical Nurse #1 that Resident #2 had touched them inappropriately in their private area while they were roommates. Review of the facility incident report revealed the certified nurse aides assigned to the third-floor unit on 9/8/2024 did not provide any written statements regarding the incident. Review of the investigative summary revealed it was not dated and was not signed indicating it was not reviewed by the Medical Director; [...]
- 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 conducted during an abbreviated survey (NY00352230), the facility did not ensure a resident's right to be free from abuse for 1 out of 3 residents (Resident #3) reviewed for abuse. Specifically, on 8/22/2024 Certified Nurse Aide #1 witnessed Resident #2 with a known history of inappropriate behaviors towards staff and others, striking Resident #3 (who had a history of wandering behavior and was care planned for supervision) on the head with a flexi-bar (rubber cylinder used in therapy) from behind. The investigative conclusion documented there is no evidence that any alleged abuse had occurred.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00331567), the facility did not ensure the accuracy of resident's assessments for 1 out of 3 residents (Resident #4) reviewed. Specifically, Resident #4 was admitted to the facility on [DATE] with a documented history of wandering but was not identified as at risk for elopement by the facility on admission. Resident #4 was placed in a room on the first floor of the facility and on 1/14/2024, the resident exited the facility front doors unescorted after they were buzzed out by the Receptionist.
- 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 interview during an abbreviated survey (NY00331567), the facility did not ensure a comprehensive patient centered care plan was developed for 1 out of 3 residents reviewed for care planning. Specifically, Resident #4 was admitted to the facility on [DATE] and had a documented history of wandering. Resident #1 exited the facility through the front doors unescorted on 1/14/2024, after being buzzed out by the Receptionist. Review of Resident #4's care plan revealed they did not have a wandering or potential for elopement care plan in place.
- D
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 during an abbreviated survey (NY00331567), the facility did not ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision for 1 out of 3 residents (Resident #4) reviewed for elopement. Specifically, on 1/14/2024 Resident #4 exited through the front doors of the facility unescorted, after being buzzed out by the Receptionist at 3:33 PM. Resident #4 with a documented history of wandering, was assigned a room on the first floor of the facility. Resident #4 exited the facility and wandered into a neighboring home near the facility and the neighbor called 911. The facility was notified of Resident #4's whereabouts around 4:31 PM by emergency medical services after the resident was transferred to the hospital.
August 14, 2024Standard inspection, Complaint inspection · 12 citations
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00347185) surveys from 8/6/2024 to 8/13/2024, the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident for 2 (Resident #88 and #213) of 3 residents reviewed for pain. Specifically, 1) Resident #88 was not administered pain medication in accordance with Physician's Orders, was not provided non-medication interventions to address pain, and had recommendations for pain management by a Physiatrist that were not reviewed by the Physician Assistant, and 2) Resident #213 was not administered pain medication in accordance with Physician's Orders.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and abbreviated (NY00347185) survey from 8/6/2024 to 8/14/2024, the facility did not ensure sufficient nursing staff to provide nursing and related services to attain or maintain the well-being of each resident in accordance with the facility assessment. This was evident for 2 (2nd and 3rd Floor) of 3 units during staffing review. [...]
- 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 observation, interview, and record review conducted during the recertification and abbreviated (NY00338972) survey from 8/6/2024 to 8/14/2024, the facility did not ensure prompt resolution of a resident's grievance and did not establish a grievance policy including all necessary elements. that includes notifying residents of their right to file a grievance . This was evident for 1 (Resident #10) of 25 total sampled residents. Specifically, 1) the facility Grievance Policy did not include the method used to notify residents of the grievance process and the resident's right to obtain the decision in writing, 2) Resident #10's Designated Representative reported the resident was missing clothing and glasses and was not provided with a prompt resolution.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00338972) survey from 8/6/2024 to 8/14/2024, the facility did not ensure an effective discharge planning process was developed and implemented focused on the resident's discharge goals, involved the resident and resident representative, and was updated. This was evident for 1 (Resident #10) of 25 total sampled residents. Specifically, upon return from the hospital and without the Designated Representative's involvement, Resident #10 was issued a Discharge Notice listing the destination as a skilled nursing facility that was not suitable for the resident's needs.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review, and interviews during the Recertification survey the facility did not ensure that each resident in need of assistance, to carry out activities of daily living, received the necessary services in a timely manner for 1 of 5 residents reviewed for Activities of Daily Living. Specifically, Resident #95 was not provided incontinence care as need or as scheduled.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey and Abbreviated survey (NY00341698) on 8/6/2024 to 8/14/2024, the facility did not ensure the necessary treatment and services, consistent with professional standards of practice, were provided to an existing pressure injury for 1 of 2 residents (Resident # 81) reviewed for pressure ulcer. Specifically Resident #81 was found with a skin opening on the sacrum on 8/1/2024 and a registered nurse did not assess the area or notify the physician until the following day.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 8/6/2024 to 8/13/2024, the facility did not ensure the physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #88) of 25 total sampled residents. Specifically, the Physician Assistant did not review a Nursing Pain Evaluation or the Physiatrist's pain management recommendations for Resident #88.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00338972) survey from 8/6/2024 to 8/14/2024, the facility did not ensure each resident received behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #10) of 25 total sampled residents. Specifically, Resident #10's behavioral health plan of care was not individualized, reviewed, and revised to address symptomology related to their mental illness diagnoses.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 08/6/24 to 08/14/24, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 2 of 25 opportunities (8%) resulted in error for 1 of 4 residents (Resident #5). Specifically, 1) Resident # 5 was administered a crushed form of Enteric coated aspirin instead of chewable and a crushed form of Depakote delayed release tablet.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and Abbreviated surveys (NY00341698) on 8/6/2024 to 8/14/2024, the facility did not ensure that rehabilitative services were provided for 1 of 2 residents (#81) reviewed for weight loss. Specifically, Resident #81 the physician's order for a Speech Therapy evaluation for slow eating and chewing, was not completed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interviews conducted during a recertification survey (08/06/24 to 08/14/24), the facility did not ensure infection control prevention practices including hand hygiene were maintained to help prevent the development and transmission of communicable diseases and infections for 2 (#15 and #4) of 32 sampled residents. Specifically, 1) Certified Nurse Aide #1's hand came in contact with Resident #15 food a during lunch meal observation and Licensed Practical Nurse #11 did not follow proper hand hygiene during a wound care treatment for Resident #4. 1) Resident #15 was admitted with diagnoses which included Hypertension, Diabetes Mellitus, Coronary Artery Disease. The Minimum Data Set, an assessment tool dated 6/30/24 documented the resident had mild cognitive impairment and required tray set up for eating. [...]
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview during the recertification survey conducted 08/06/24 to 08/14/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #51) reviewed. Specifically, there was no documented evidence Resident #51 was offered, declined, or educated on the pneumococcal immunization.
July 30, 2024Complaint inspection · 2 citations
- 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 conducted during an abbreviated survey (NY00334044), the facility did not ensure residents right to be free from abuse for 1 of 3 residents (Resident #3) reviewed for abuse. Specifically, on 2/21/24, Dietary Aide #15 was witnessed by a Certified Nurse Aide #14, verbally threatening Resident #3 and pulling on Resident #3 beaded necklace. Resident #3 written statement documented that a staff member entered his room and held them by the shirt and chest area and verbally threatened him. Resident #3 was assessed with no injuries. Facility Investigation concluded abuse occurred.
- 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 observations, interviews and record review conducted during an abbreviated survey (NY00342153) the facility did not develop or implement a comprehensive person-centered care plan for Resident #1. Specifically, the heels of Resident #1 were not offloaded and or heel booties were not applied as per physician order and as per care plan.
October 27, 2021Standard inspection · 4 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 and staff interview conducted during a Recertification Survey the facility did not ensure labeling, dating and the monitoring of refrigerated food was maintained in accordance with Professional Standards of Food Safety. Specifically, prepared and frozen foods in the kitchen refrigerator and in the dry food storage room were not labeled and or not dated.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteF583 Based on observation and interviews conducted during recent recertification survey the facility did not ensure privacy was maintained for 1 of 1 resident (#72) reviewed for privacy. Specifically, 2 residents (#72 and #9) of the opposite sex were placed in adjoining rooms with a shared bathroom.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview conducted during recertification survey, for 1 of 1 resident (Resident #158) reviewed for catheters, and 1 of 3 residents reviewed for infection control (Resident # 96,) the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of infections. Specifically, Resident #158 catheter (urinary drainage tube) drainage bag (bag for collecting urine from the urinary drainage tube) was observed uncovered and on the floor on multiple days of survey, and Resident #96, had uncovered oxygen tubing and humidification bottles on several observations.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observations, interviews and record review conducted during a recertification survey, the facility did not ensure accurate staffing information was posted in a prominent place readily accessible to residents, staff, and visitors. Specifically, 1) the facility did not post the total and actual hours of licensed and unlicensed staff directly responsible for resident care daily and 2) did not provide complete staffing records for the 18 months reviewed.
August 7, 2018Standard inspection · 15 citations
- 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 interview and record review conducted during a recertification survey, the facility did not ensure that each resident, or designated representative of cognitively impaired residents, was given the opportunity, if so desired, to formulate a written advance directive. This was evident for 2 of 3 residents reviewed for advanced directives (#102 and #46). Specifically, (1) the designated representative for Resident #102 was not educated regarding the right to have an advanced directive formulated for the resident not to be resuscitated and (2) Resident #46 had a physician's order not to be intubated and there was no documented evidence that Resident #46 gave written consent for this order.
- D
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure that it implemented written policies and procedures for reporting an allegation of abuse made by a resident for 1 of 4 residents (#82) reviewed for abuse.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteSurveyor: [NAME], [NAME] A. Based on record review and interview conducted during a recertification survey, the facility did not ensure that all Minimum Data Set (MDS; a resident assessment and screening tool) were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days of the final completion date for 3 of 4 residents reviewed for resident assessment. Specifically, residents (R) #1, #3, and #4 did not have the MDS data submitted within 14 days of completion of the MDS assessment. The finding is: The following residents were reviewed for Resident Assessment: - R #1 had an MDS admission Assessment with an ARD (assessment reference date) of 7/3/18, a completion date of 7/10/18 was submitted on 7/31/18; [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not provide the necessary care and services for 1 of 1 resident (#5) reviewed for respiratory care. Specifically, the facility did not provide Resident #5 who had a tracheostomy (an incision is made on the anterior aspect of the neck and opening a direct airway through an incision in the trachea) with a device to enable the resident to speak more normally and/or communicate with others. The finding is: Resident # 5 had diagnoses including Malignant Neoplasm of the bronchus and lungs and Respiratory Failure. The admission Minimum Data Set (MDS; a resident assessment and screening tool) of 12/27/17 indicated the resident had no cognitive impairment and required tracheostomy care. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not provide the necessary care and treatments to prevent skin breakdown for 1 of 1 resident (#28) reviewed for non pressure related skin ulcer/wound. Specifically, the treatment plan was not revised to prevent further recurrence of a chronic skin irritation. The finding is: Resident # 28 was a admitted with diagnoses including Seizure Disorder and End Stage Renal Disease. The Quarterly Minimum Data Set (a resident assessment and screening tool) of 5/2/18 documented the resident scored 11 out of 15 on the Brief Interview of Mental Status (a test used to measure orientation and memory recall) indicating she was moderately cognitively intact. [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure that an audiology evaluation was performed as ordered by the medical provider for 1 of 2 residents (#46) reviewed for vision and hearing. The finding is: Resident #46 has diagnoses including Diabetes Mellitus, Cardiovascular disease, and Renal Insufficiency. The Annual MDS (Minimum Data Set; a resident assessment and screening tool) dated 2/14/18 documented that the resident scored a 15 out of 15 on the BIMS (Brief interview for Mental Status) indicating the resident is cognitively intact. The MDS further indicated that the resident's hearing was adequate and did not use hearing aids. A subsequent Quarterly MDS dated [DATE] documented adequate hearing and no hearing aid was being used. [...]
- 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 interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 2 residents (#94) reviewed for urinary incontinence that the necessary care to promote and maintain bladder continency to the extent possible was provided. Specifically, the type of urinary incontinence was not identified and a patient-centered care plan, based on the type of incontinence and maintenance versus restorative goals and interventions, was not developed to address the bladder incontinence across all shifts.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure for 2 out of 7 residents reviewed for nutrition (#46 and #94) that there was coordination between nursing and dietary to ensure that the fluids offered to the resident did not exceed the physician's order to prevent fluid overload.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility (1.) did not provide for 1 of 1 residents (#5), reviewed for respiratory care, a device to enable the resident to speak more clearly and to be more easily understood during conversation with others. Additionally, (2.) manual resuscitative devices (ambu bags) were not easily accessible in case of an emergency for resident (#5) and for one random resident (#51) with a tracheostomy (trach) tube on the First floor unit. A tracheostomy is a surgical procedure which consist of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not provide ongoing evaluation and management of pain for 1 of 4 residents (#46) reviewed for pain management.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that medical supervision was provided for 1 of 5 residents (#45) reviewed for nutrition. Specifically, the physician or the Nurse Practitioner (NP) did not address the resident's significant unplanned weight loss and the abnormal nutritionally-related laboratory values in light of adequate protein, calories and fluid consumption. The finding is: Resident #45 was admitted to the facility on [DATE]. The resident's admitting diagnoses included Anemia, Diabetes Mellitus, and Chronic Kidney Disease. The Significant Change Minimum Data Set (MDS; a resident assessment and screening tool) done on 2/2/18 noted that the resident had severe cognitive impairment, required total assistance for all activities of daily living, weighed 116 lbs. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. This was evident for 2 of 6 residents (#267 and #38) observed during a medication pass for a total of 3 out of 31 opportunities for error resulting in a medication error rate of 9.6%.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that the necessary dental services were provided in a timely manner including arrangements to obtain dentures for 1 of 3 residents (Resident #94) reviewed for dental services.
- D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 7 out of 10 alert and oriented residents from 2 out of 3 units, that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack they were not provided with an evening snack.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that measures were in place to prevent the spread of infection and cross contamination for 1 of 1 resident reviewed for respiratory care (Resident #5). The resident was observed on multiple occasions using his bare fingers to cover his tracheostomy tube (a type of airway inserted directly into the trachea) to communicate with others after touching objects and surfaces, potentially contaminating the tracheostomy (trach) tube without using proper hand hygiene. Additionally, resident care items including oxygen tubes and feeding supplies were stored in containers that were placed directly on the floor on 2 out 3 facility units (1st and 3rd).
Fire safety inspections
23 fire safety citations on file: 7 on August 14, 2024, 6 on October 27, 2021, 10 on August 7, 2018.
Every fire safety citation23 citations
- E
Use approved construction type or materials.
K 161 · August 14, 2024 · Waiver
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 14, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 14, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 14, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 14, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 14, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 14, 2024 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · October 27, 2021 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 27, 2021 · Corrected (the home has a date of correction)
- E
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · October 27, 2021 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 27, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 27, 2021 · Corrected (the home has a date of correction)
- C
Include a process for Emergency Preparedness collaboration.
E 9 · October 27, 2021 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 7, 2018 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · August 7, 2018 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 7, 2018 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 7, 2018 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 7, 2018 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 7, 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 · August 7, 2018 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 7, 2018 · Corrected (the home has a date of correction)
- C
Provide family notifications of emergency plan.
E 35 · August 7, 2018 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · August 7, 2018 · Corrected (the home has a date of correction)