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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
10D
1E
1F
Potential for minimal harm
0A
0B
0C
October 16, 2024Standard inspection, Complaint inspection · 5 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 facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #65 and Resident #6) of 13 residents reviewed for abuse. On 8/6/2024, Resident #6 grabbed Resident #65 by the shirt causing Resident #65 to turn over in his wheelchair causing scratches to the left shoulder, 3 skin tears to the left forearm, and a skin tear on the right hand to reopen. Resident #65 retaliated and struck Resident #6 in the face causing a laceration to the resident's right upper lip. The facility's failure to protect the residents' right to be free from physical abuse resulted in actual Harm for Resident #65 and Resident #6.
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on facility policy review, medical record review, facility documentation review, resident financial statements review, and interviews, the facility failed to protect the residents' right to be free from misappropriation and/or exploitation when a staff member deliberately used multiple residents' personal monetary funds without consent for personal gain for 7 residents (Resident #16, Resident #55, Resident #69, Resident #25, Resident #54, Resident #52, and Resident #61) of 53 sampled residents reviewed for misappropriation of personal funds.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to provide a homelike environment for 3 residents (Resident #73, Resident #40, and Resident #33) of 81 residents reviewed for a homelike environment.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interviews the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #55) of 20 residents reviewed for accuracy of MDS assessments.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, medical record review, observation, and interviews the facility failed to follow infection control practices during medication administration for 1 resident (Resident #59) of 3 residents observed for medication administration.
September 21, 2023Complaint inspection · 3 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 review of a facility policy, medical record review, review of a facility investigation, and interview the facility failed to protect the resident's right to be free from physical abuse of 1 resident (#3) of 7 residents review for abuse of 13 resident sampled residents. The Facility's failure to prevent resident to resident altercation resulted in actual harm for Resident #3 when Resident #4 threw a plastic coke bottle and hit Resident #3 in the face causing a contusion under her left eye and yelled at Resident #3 causing her to cry and be afraid.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of a facility policy, facility investigations, medical record review, observation and interview, the facility failed to report allegations of abuse for 1 resident (#4) and failed to report an allegation of abuse within the federal required timeframe for 1 resident (#12) of 8 residents reviewed for abuse.
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to obtain an admission Physician's Order for wound care for 1 Resident (#2) of 3 residents reviewed for wound care.
December 1, 2021Standard inspection · 3 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to separate resident and staff food items in 3 of 3 resident pantry rooms, failed to discard expired food in 3 of 3 resident pantry rooms, and failed to maintain a sanitary environment in 3 of 3 resident pantry rooms.
- 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, observation, and interview, the facility failed to maintain a falls intervention for 1 resident (#29) of 6 residents reviewed for accidents.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide an appropriate set-up for intravenous (IV) fluid administration for 1 resident (#18) of 4 residents observed.
March 27, 2019Standard inspection · 3 citations
- 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 facility policy review, medical record review, observation, and interview, the facility failed to revise a comprehensive care plan to address use of an anticoagulant medication (a blood thinner) for 1 resident #79 of 8 residents reviewed for anticoagulant medication use.
- 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 medical record review, observation, and interview the facility failed to ensure resident (#19) had a right hand wrist orthosis (splint) device was in place for 1 resident (#19) of 4 residents reviewed for positioning and mobility of 31 sampled residents.
- D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Inspectors wroteBased on facility policy review, observation, and interview the facility failed to provide timely dental services for 1 resident #86 of 31 sampled residents.
Fire safety inspections
11 fire safety citations on file: 7 on October 16, 2024, 1 on December 1, 2021, 3 on March 27, 2019.
Every fire safety citation11 citations
- D
Address subsistence needs for staff and patients.
E 15 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · October 16, 2024 · 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 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · October 16, 2024 · 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 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 16, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 1, 2021 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · March 27, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 27, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 27, 2019 · Corrected (the home has a date of correction)