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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
0E
1F
Potential for minimal harm
0A
0B
0C
May 17, 2023Standard inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (#50) of 24 residents reviewed for abuse.
October 16, 2019Standard inspection · 2 citations
- 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 review of facility policy, medical record review, observation, and interview, the facility failed to revise the care plan to include the use of the back and collar brace for 1 resident (#35) of 25 residents reviewed for care plans.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, review of the facility's falls documentation, observation, and interview, the facility failed to implement appropriate interventions to prevent falls, failed to complete a fall risk assessment, and failed to complete a fall investigation for 1 resident (#70) of 3 residents reviewed for accidents.
September 19, 2018Standard inspection · 5 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 facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with undated, unlabeled foods, expired foods, opened to air food items, and dirt and/or debris in 1 of 3 food storage bins, and improper cleaning of 1 of 3 food storage bins in the kitchen. The facility failed to maintain sanitary resident nourishment refrigerators with undated, unlabeled foods and expired foods, in 3 of 3 food nourishment refrigerators affecting 75 of 76 residents.
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on medical record review and interview, the facility failed to complete an annual Minimum Data Set (MDS) for 1 resident (#1) of 25 residents reviewed.
- 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 review of facility policy, medical record review, observation, and interview, the facility failed to revise the Comprehensive Care Plan to address post fall interventions for 1 resident (#22) of 25 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 wroteBased on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of psychotropic medications for 1 resident (#38) of 5 residents reviewed for unnecessary medications of 25 residents sampled.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to distribute and serve food under sanitary conditions for 1 unit of 3 units observed for dining, and failed to perform proper hand hygiene after providing peri-care for 1 resident of 2 residents observed for peri-care.
Fire safety inspections
9 fire safety citations on file: 3 on May 17, 2023, 2 on October 16, 2019, 4 on September 19, 2018.
Every fire safety citation9 citations
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · May 17, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 17, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · May 17, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 16, 2019 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · October 16, 2019 · 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 · September 19, 2018 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 19, 2018 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 19, 2018 · Corrected (the home has a date of correction)
- C
Establish an Emergency Preparedness Program (EP).
E 1 · September 19, 2018 · Corrected (the home has a date of correction)