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 4 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
0F
Potential for minimal harm
0A
0B
0C
December 12, 2024Standard inspection · 0 citations
April 6, 2023Standard inspection · 1 citation
- 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 wroteBased on interview and record review the facility failed to implement medication regimen review (MRR) recommendations for medication administration parameters of physician's orders for 1 of 5 residents and failed to ensure MRRs were reviewed by the physician for 1 of 5 residents reviewed for unnecessary medications from a total sample of 39 residents. (#8, #43)
May 6, 2021Standard inspection · 3 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to ensure accurate narcotic reconciliation for 1 of 1 narcotic medication reviewed, and failed to ensure safe administration of medications for 6 of 19 residents of a total sample of 51 residents, (#2, #35, #48, #72, #77 and #108).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound care treatment in accordance with physician's orders and acceptable standards of practice for two skin tears for 1 of 1 resident reviewed for non-pressure skin conditions of a total sample of 51 residents, (#28).
- D
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 wroteBased on observation, interview, and record review, the facility failed to ensure the controlled medication compartment was properly secured on 1 of 6 medication carts, (Arbor Oak medication cart).
Fire safety inspections
5 fire safety citations on file: 4 on April 6, 2023, 1 on May 6, 2021.
Every fire safety citation5 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 6, 2023 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 6, 2023 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · April 6, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 6, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 6, 2021 · Corrected (the home has a date of correction)