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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
1E
0F
Potential for minimal harm
0A
0B
0C
April 24, 2024Standard inspection · 0 citations
December 9, 2021Standard inspection · 0 citations
March 29, 2019Standard inspection · 7 citations
- E
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 wrote3. The facility staff failed to monitor targeted behaviors while Resident #20 was receiving Ativan and Restoril. Resident #20 was admitted to the facility on [DATE] with the following diagnoses, but not limited to cancer, heart failure, high blood pressure, thyroid disorder, anxiety and depression. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/13/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #20 was also coded as requiring extensive assistance of 1 staff member for dressing and limited assist of 1 staff member for personal hygiene. The resident was coded as being totally dependent on 1 staff member for bathing. [...]
- 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, the facility staff failed to provide the comprehensive care plan goals to the receiving provider for 2 of 15 residents (Resident #15 and Resident #23).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer the correct amount of eye drops to 1 of 15 residents (Resident #21).
- 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, the facility staff failed to assess for pain prior to wound care for 1 of 15 residents in the survey sample (Resident #29).
- 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 and clinical record review, the facility staff failed to have scheduled medications available for administration to 2 of 15 residents (Resident #23 and Resident #28).
- D
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow the physician orders for 1 of 15 residents (Resident #1).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview facility document review, and clinical record review, the facility staff failed to follow infection control guidelines for wound care for 1 of 15 residents (Resident #29).
Fire safety inspections
5 fire safety citations on file: 2 on December 9, 2021, 3 on March 29, 2019.
Every fire safety citation5 citations
- D
Have proper power supply for life support equipment.
K 915 · December 9, 2021 · 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 · December 9, 2021 · Corrected (the home has a date of correction)
- F
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 · March 29, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 29, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 29, 2019 · Corrected (the home has a date of correction)