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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
4E
2F
Potential for minimal harm
0A
0B
0C
October 21, 2024Standard inspection · 12 citations
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents selected for review. Based on observation, interview, and record review, the facility failed to provide care plan meetings for four Residents (R) 13, R2, R7 and R57, as required.
- E
Keep all essential equipment working safely.
Inspectors wroteThe facility reported a census of 74 residents. Based on observation, interview, and record review, the facility failed to ensure all resident equipment in one of the four neighborhoods were in clean, safe condition, regarding one toilet seat riser with legs and handles.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteThe facility reported a census of 74 residents. Based on observation, interview, and record review, the facility failed to ensure a clean environment in one of the four neighborhoods regarding soiled, stained privacy curtains in a shower room in one of the four neighborhoods.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident's (R)27's, regarding the care and maintenance of her personal humidifier.
- 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 wroteThe facility reported a census of 74 residents with 20 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plans for two Residents (R)59 and R 70, regarding footrests for their wheelchairs.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents included for review, which included two residents reviewed for activities of daily living. Based on observation, interview, and record review, the facility failed to ensure two Resident (R)13 and R37 received grooming assistance.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents sampled, including two residents reviewed for positioning. Based on observation, interview, and record review, the facility failed to properly position two Residents (R)59 and R 70, regarding footrests for their wheelchairs.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents sampled, including one resident reviewed for respiratory services. Based on observation, interview, and record review, the facility failed to properly clean and maintain a humidifier (a device for keeping the atmosphere moist in a room) in one Resident's (R)27's room.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents selected for review, which included one resident reviewed for dialysis (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). Based on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one Resident (R)2 who received dialysis three times a week.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteThe facility reported a census of 74 residents with 20 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)2, received medications within the physician ordered parameters.
- 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 wroteThe facility reported a census of 74 residents with 20 residents sampled, that included six residents reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to assess one Resident (R)44, for adverse effects of an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 74 residents, with 20 sampled. Based on observation, interview and record review, the facility failed to use proper hand hygiene while completing wound care for one Resident (R)27.
May 6, 2024Complaint inspection · 1 citation
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThe facility reported a census of 81 residents. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to prevent the staff neglect of Resident (R) 1. On 11/27/23 at 08:45 AM Certified Medication Aide (CMA) R entered cognitively impaired R1's room and observed R1 on the floor with her legs extended in the doorway of the closet. CMA R administered medications to R1 while she remained on the floor, and then left the resident's room. CMA R failed to report to any staff member that R1 was on the floor. At 12:45 PM, four hours later, CNA M heard noises coming from R1's room and when she entered the residents' room, she observed R1 sitting on the floor next to her bed. CNA M asked Housekeeping Staff U, who was also in the room, to immediately get Licensed Nurse (LN) G. [...]
March 7, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteThe facility reported a census of 83 residents. The sample included three residents reviewed for pain-controlled substance medication. Based on observation, interview, and record review, the facility failed to prevent a medication error when Licensed Nurse (LN) I failed to document in Resident (R)1's Electronic Health Records (EHR). On 02/28/24 at 06:00 AM, LN I administered oxycodone (opioids [narcotic analgesics]), five milligram (MG) tablet, as an as needed (PRN) pain medication. On 02/28/24 at 08:00 AM, two hours later, LN H administered R1's scheduled oxycodone, which was to be administered one hour prior to leaving for dialysis (a blood purifying treatment given when kidney function in not optimum), for pain. The facility failed to ensure no use of as needed (PRN) administered within a six-hour time frame of the scheduled doses, as ordered by the physician. [...]
December 19, 2022Standard inspection · 11 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility identified a census of 79 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 12/13/22 at 07:06AM an initial walkthrough of the facility's kitchen was completed. An inspection of the kitchen's walk-in refrigerator revealed that the air-conditioning unit was leaking clear liquid. The fluid was dripping down onto several shelves stored below the unit. An inspection of the shelves revealed two bags of collard greens, one box of cut okra, and one box of hot dogs were covered in ice. On 12/19/22 at 01:20PM Dietary Staff BB stated that staff should be going in an inspecting the storage areas daily for cleanliness and equipment function. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observations, interviews, and record reviews, the facility failed to provide Resident (R)5 with dignity during basic cares. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), epilepsy (brain disorder characterized by repeated seizures), intellectual disabilities, muscle weakness, Lennox-Gastuat syndrome (severe condition with recurrent epileptic seizures starting from early childhood), and dysphagia (swallowing difficulty). [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were provided for Resident (R) 30's wheelchair to prevent his feet from dragging on the floor. This deficient practice placed R30 at risk for accidents and injuries.
- 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 wroteThe facility identified a census of 79 residents. The sample included 18 residents with 18 residents reviewed for care plan revisions. Base on observation, record review, and interviews, the facility failed to revise care plan interventions related to Resident (R)26's ongoing exit seeking behaviors and need for a Wanderguard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed R26 at risk for wandering related accidents and unmet care needs. Findings Included: [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents with one reviewed for activities. Based on observations, interviews, record review, and policy review, the facility failed to ensure Resident (R) 30 was provided with a meaningful activity program to address his assessed needs. This placed him at risk for impaired psychosocial wellbeing including boredom, agitation and restlessness. Findings Included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. [...]
- 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 wroteThe facility identified a census of 79 residents. The sample included 18 residents with two residents reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to provide the necessary services for Resident (R) 6's multiple contractures (abnormal fixation of a joint) to prevent further loss of ROM and mobility, which placed R6 at risk of a possible decline in independence, skin breakdown and impaired psychosocial wellbeing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents with four residents reviewed for accidents. Base on observation, record review, and interviews, the facility failed utilize Resident (R)5's wheelchair seatbelt resulting in a minor-injury fall. The facility additionally failed to monitor, check placement, or function of R26's WanderGuard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed both residents at risk for preventable accidents and related injuries. Findings Included: [...]
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents with one resident reviewed for dementia care services. Based on observation, record review, and interviews, the facility failed to provide dementia (progressive mental disorder characterized by failing memory, confusion) care and treatment for Resident (R)76, a cognitively impaired resident displaying dementia related symptoms. This deficient practice placed R76 at risk for impaired ability to achieve and/or maintain her highest practicable level of physical and emotional wellbeing. Finding Included: - The Medical Diagnosis section within R76's Electronic Medical Records (EMR) included diagnoses of dysphagia (swallowing difficulty), difficulty walking, hearing loss, atrial fibrillation (rapid, irregular heartbeat), cognitive communication deficit, and a history of malignant neoplasm (cancer). [...]
- 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 wroteThe facility identified a census of 79 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified an inappropriate indication for use an antipsychotic (medication used to treat severe mental conditions) medication for Resident (R) 30 who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This deficient practice had the potential of unnecessary psychotropic medication administration, thus leading to possible harmful potential side effects.
- 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 wroteThe facility identified a census of 79 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure AN appropriate indication for use of an antipsychotic (medication used to treat severe mental conditions) medication for Resident (R) 30 who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This deficient practice had the potential of unnecessary psychotropic medication administration, thus leading to possible harmful potential side effects.
- 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 wroteThe facility identified a census of 79 residents and 10 medication carts. Based on observation, record review, and interview, the facility failed to discard an outdated individual insulin (a hormone which regulates blood sugar) pen in one of the medication carts. This deficient practice left the affected resident at risk for adverse consequences or less effective medication treatment.
May 13, 2021Standard inspection · 4 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 74 residents with 22 selected for review, which included eight residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure appropriate fall interventions were in place by determining the causal factors of the fall for four of the eight sampled residents. Of these Resident (R) 47 fell and sustained a nasal fracture and forehead laceration which required 11 sutures, with R2 and R33 experiencing repeated falls. The facility further failed to investigate and develop interventions for one of the eight residents, R51 who sustained repeated skin tears to the arms on three occasions.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 74 residents. Based on observation, interview and record review, the facility failed to ensure sanitary laundering of linen soiled with blood to prevent cross contamination with blood borne pathogens.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteThe facility reported a census of 74 residents with 22 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for four of the residents sampled, including Resident (R) 2, R33, and R47 regarding timely interventions after falls to prevent further falls, and timely interventions to prevent further skin tears on the arms of one sampled resident R51.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteThe facility reported a census of 74 residents with 22 residents sampled, including six residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to identify, plan, and implement timely interventions to maintain nutritional status for one of the six residents reviewed, Resident (R) 172.
Fire safety inspections
35 fire safety citations on file: 11 on October 21, 2024, 11 on December 19, 2022, 13 on May 13, 2021.
Every fire safety citation35 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 21, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 21, 2024 · 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 · October 21, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 21, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 21, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 21, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 21, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 21, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 21, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · October 21, 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 21, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 19, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 19, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · December 19, 2022 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 19, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · December 19, 2022 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · December 19, 2022 · 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 · December 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 19, 2022 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 19, 2022 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · December 19, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · December 19, 2022 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · May 13, 2021 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 13, 2021 · Waiver
- F
Have simulated fire drills held at unexpected times.
K 712 · May 13, 2021 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 13, 2021 · Waiver
- F
Ensure proper usage of power strips and extension cords.
K 920 · May 13, 2021 · 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 · May 13, 2021 · Corrected (the home has a date of correction)