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 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
9E
3F
Potential for minimal harm
0A
0B
3C
November 2, 2023Standard inspection · 13 citations
- E
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 observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 34 residents in the survey sample; Residents #94, #11, #29, #97, #106, #23, #35, and #46.
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 34 residents in the survey sample, Resident #29.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to protect the dignity of 1 of 34 residents in the survey sample; Resident #65.
- 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 interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence periodic review of Advance Directives for three of 34 residents in the survey sample; Residents #78, #33 and #41.
- 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 and clinical record review, the facility staff failed to notify the physician of a possible need to alter treatment for one of 34 residents in the survey sample, Resident #35.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed for one of 34 residents in the survey sample; Resident #24.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for one of 34 residents in the survey sample; Resident #94.
- 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement interventions for the prevention of a decrease in range of motion for one of 34 residents in the survey sample, Resident #46.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services per the physician orders for two of 34 residents in the survey sample, Residents #46 and #97.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement bed rail requirements for one out of 34 residents in the survey sample, Resident # 106.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 34 residents in the survey sample, Resident #35.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one of 34 residents in the survey sample; Resident #94. The facility had two medication errors out of 35 opportunities, resulting in a medication error rate of 5.71%.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 34 residents in the survey sample, Residents #11 and #106.
February 8, 2022Standard inspection · 19 citations
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote4. The facility staff failed to implement the comprehensive care plan for bathing for Resident #52. Resident #52 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 12/30/2021, the resident scored an 8 of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as not having had a shower or bath during the lookback period. The comprehensive care plan dated 11/29/2021 documented, in part, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia, Limited Mobility .BATHING/SHOWERING - Provide sponge bath when a full bath or shower cannot be tolerated. [...]
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program by documenting the location of the resident's pain and implementing non-pharmacological interventions prior to the administration of prn (as needed) pain medications for two of 51 residents in the survey sample, Residents # 25 and # 88.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature during lunch service on 2/7/2022, with the potential to affect 53 of 54 residents on the North unit receiving a meal tray.
- 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 resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon a reported grievance for missing personal items for one of 51 residents in the survey sample, Resident #21. The facility staff failed to promptly respond to a known grievance for missing clothing items for Resident #21.
- 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement facility initiated transfer requirements for 3 of 51 residents in the survey sample, Residents #96, #81 and #54. The facility staff failed to evidence a physician note regarding facility initiated hospital transfers for Residents #96 and #81 and failed to evidence required information provided to hospital staff for facility initiated transfers for Residents #81 and #54.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide an accurate assessment for one of 51 residents, Resident #32. The facility staff failed to complete an accurate MDS (minimum data set), an annual assessment, for Resident #32.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on family interview, facility document review, and clinical record review, it was determined the facility staff failed to provide ADL (activities of daily living) care for one of 51 residents in the survey sample, Resident #52. Resident #52, a dependent resident, was not provided baths.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the physician ordered interventions for the prevention of pressure injuries for one of 51 residents in the survey sample, Resident # 11. The facility staff failed to place a donut pillow on the resident's left ankle.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to implement interventions to prevent an accident for two of 51 residents in the survey sample, Residents # 10 and #32.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory services as ordered, and in a sanitary manner, for three of 51 residents in the survey sample, Residents #74, #28, and #41.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to complete an assessment for the use of side rails and/or failed to have consent, after discussion of the risks and benefits for the use of the bed rails, for three of 51 residents in the survey sample, Residents #11, #40 and #28.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence documentation for one of four CNA (certified nursing assistant) employee records reviewed, CNA #3. For CNA #3, the facility staff failed to evidence documentation of an annual performance review.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for 1 of 51 residents in the survey sample, Resident #83. The facility staff failed to ensure that the PASRR (Pre-admission Screening and Resident Review) level 2 screening was available on the clinical record.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to administer the pneumococcal immunization for one of five resident immunization record reviews, Resident 91. Resident #91's RR (resident representative) provided consent for the pneumococcal immunization on 12/29/21. The facility staff failed to evidence the immunization was administered to the resident.
- D
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to track all employees' COVID-19 vaccination status, and failed to implement the facility policy for employee vaccination tracking for 6 of 100 employees sampled, OSM (other staff member) #10, #11, #12, #13, #14, and #15. The facility staff failed to implement their policy for COVID-19 employee vaccination status tracking, and failed to track COVID-19 vaccination status for OSM #10, #11, #12, #13, #14, and #15, all employees of [name of Hospice Company].
- D
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to have an annual inspection of three resident beds of 52 beds in the survey sample, Resident #11, #40, and #28.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on staff interview, facility document review, and employee record review, it was determined the facility staff failed to ensure one of four CNA (certified nursing assistants) had required training, CNA #2. The facility failed to provide CNA #2 training in dementia care.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to make available the results of the most recent survey. The facility staff failed to include the results of the abbreviated survey ending 12/29/2021 in the survey results notebook in the lobby.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to post the daily nursing staff posting on 2/6/2022.
November 18, 2019Standard inspection · 17 citations
- K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote4. Resident #48 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's (1), schizophrenia (2) and depressive disorder (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/23/19, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. The resident was coded as independent for bed mobility, transfer, walking in room and corridor, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. The annual MDS (minimum data set) assessment with ARD (assessment reference date) of 3/23/19 coded the resident's current tobacco use, as yes. The care plan dated 2/6/19, documented in part, Focus: Smoking: Non-compliant with smoking policy. The Goal: [...]
- 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 wroteBased on staff interview and facility document review it was determined that the facility staff failed to ensure RN (Registered Nurse) coverage for at least 8 hours a day, every day. A review of the staffing schedules and postings revealed several dates where there was no RN on duty.
- 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, staff interview, and facility document review, it was determined that the facility staff failed to prepare and serve food in a sanitary manner.
- F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on staff interview, facility document review, and employee record review, it was determined that the facility staff failed to meet the training requirements for eight of 15 CNA (Certified Nursing Assistant) employee records reviewed, (CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, CNA #2 and CNA #100.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident interview, facility staff interview, and facility document review, it was determined that the facility staff failed to assist residents to exercise their right to vote. The facility staff failed to offer residents who could vote the opportunity to do so for the November 2019 election.
- E
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 observation and facility staff interview, the facility staff failed to maintain a comfortable home-like environment in two of two common areas on the north wing, and in the main dining room. On 11/13/19, observations revealed temperatures in the north wing common areas were 61 degrees, and the temperature in the main dining room was 64 degrees.
- E
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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence documentation that the care plan goals were sent to the hospital upon transfer for 5 of 60 Residents in the survey sample, Residents #56, #19, #81, #82, and #105
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure professional standards of quality for as needed pain medications for two of 60 residents in the survey sample, Resident #81 and #87. The facility staff failed to clarify two PRN (as needed) pain medication orders for Resident #81 to determine when each medication should be administered based on pain level parameters. The facility staff failed to clarify two PRN (as needed) pain medication orders for Resident #87 to determine when to administer each medication based on pain level parameters.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess a resident to administer their medications independently for one of 60 residents in the survey sample, Resident #87. Resident # 87 was observed administering her nebulizer treatments without supervision from a nurse on two occasions; review of the clinical record failed to evidence a self-administration of medication assessment for the resident.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, facility staff failed to ensure two of 60 residents in the survey sample, Residents #72, and #82, were free from abuse. On 9/24/19, Resident #304 hit Resident #72 on the face with his open hand, causing a red area on Resident #72's face and pushed Resident #72, hitting his knee on the doorframe causing an abrasion. On 7/12/19, Resident #53 hit Resident #82 with her cane causing a bruises to her fifth digit of the right hand. The Findings Included: 1. Resident #72 was admitted to the facility on [DATE]. His diagnoses included diabetes, delusional disorders, and intellectual disability. Resident #72's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 10/15/2019. [...]
- 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the ombudsman of a transfer to the hospital and evidence a notice was given to the resident and/or responsible party with the reason for the transfer for one of 60 residents in the survey sample, Resident #19.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, it was determined that the facility staff failed to accurately code the MDS (Minimum Data Set) assessment for smoking status for 2 of 60 residents in the survey sample; Residents #32 and #45. The facility staff coded the Resident #32 as not being a current tobacco user on the most recent comprehensive assessment dated [DATE] and the resident was observed smoking. The facility staff coded the Resident #45 as not being a current tobacco user on the most recent comprehensive assessment dated [DATE], when the resident stated during interview that (Resident #45) does go outside to smoke about twice a day with another resident.
- 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 observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement the comprehensive care plan for one Resident, Resident #25, in a sample of 60 Residents. The facility staff failed to implement the interventions for Resident #25's urinary catheter care plan. The Findings Included: Resident #25 was admitted to the facility on [DATE]. His diagnoses included anxiety disorder, depression, and urinary retention. Resident #25's most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an Assessment Reference Date (ARD) of 09/04/2019. The Brief Interview for Mental Status (BIMS) scored Resident #25 at a 15, indicating no impairment. Resident #25 was coded as requiring extensive assistance of two or more people for all Activities of Daily Living (ADLs). [...]
- 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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan to address a fall for one of 60 residents in the survey sample; Resident #19.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure respiratory care consistent with professional standards of practices for one of 60 residents in the survey sample, Resident # 86. The facility staff failed to ensure a full E-cylinder of oxygen for Resident #60 was properly stored and secured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate medical record for one of 59 residents, Resident #48. The physician's progress notes failed to document discussion regarding alternative to smoking.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview and facility document review it was determined that the facility staff failed to ensure a continuous, accurate posting of the facility staffing. Observation of the staff posting upon entrance to the facility on [DATE] 11:40 AM, revealed the staff posting for Friday, 11/8/19. There was no evidence of a current posting was observed.
Fire safety inspections
21 fire safety citations on file: 3 on November 2, 2023, 8 on February 8, 2022, 10 on November 18, 2019.
Every fire safety citation21 citations
- D
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 2, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · November 2, 2023 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 2, 2023 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · February 8, 2022 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · February 8, 2022 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · February 8, 2022 · Corrected (the home has a date of correction)
- C
Establish procedures for tracking staff and patients during an emergency.
E 18 · February 8, 2022 · Corrected (the home has a date of correction)
- C
Provide a means of sharing information on occupancy/needs.
E 34 · February 8, 2022 · Corrected (the home has a date of correction)
- C
Establish emergency prep training and testing.
E 36 · February 8, 2022 · Corrected (the home has a date of correction)
- C
Establish staff and initial training requirements.
E 37 · February 8, 2022 · Corrected (the home has a date of correction)
- C
Implement emergency and standby power systems.
E 41 · February 8, 2022 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · November 18, 2019 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · November 18, 2019 · Corrected (the home has a date of correction)