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 54 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
37D
14E
0F
Potential for minimal harm
0A
0B
2C
August 25, 2023Standard inspection · 29 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services to prevent the development of a pressure ulcer at an advanced stage for one Resident (Resident #413) in a survey sample of 64 Residents, resulting in harm for Resident #413. The facility self-identified this deficient practice before the survey, resulting in past non-compliance being achieved on 7/26/23.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on Resident interview, staff interview, facility documentation review, the facility staff failed to respond to Resident Council grievances These grievance included A) laundry not being returned timely B) items being lost, C) food not being good, D) lack of showers, E) cleanliness of the facility, and F) lack of cleaning in their rooms.
- E
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on Resident interview and staff interview the facility staff failed to uphold Resident Rights regarding the right to receive mail and receive mail unopened affecting 14 Residents (Resident #7, #13, #23, #41, #44, #47, #53, #58, #61, #67, #82, #84, #92, and Resident #98) in a survey sample of 64 Residents.
- E
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview, clinical record, and facility documentation the facility staff failed to ensure residents are free from neglect and misappropriation of property for 21 Residents (#'s 42, 92, 23, 6, 363, 87, 52, 9, 38, 14, 97, 64, 7, 67, 78, 69, 56, 31, 364, 72, 88, 82 and 78), in a survey sample of 62 Residents.
- 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 wroteBased on observation, Resident Interview, Facility staff interview and record review, the facility staff failed to revise 1 of 64 sampled residents care plan.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide assistance with activities of daily living (ADL) for Residents who were dependent upon facility staff for such care, affecting 3 Residents (Resident #10, #29, and #87) in a survey sample of 64 Residents.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on resident and staff interviews, clinical record review and facility's documentation, the facility staff failed to ensure 2 of 64 residents (Resident #107 and #413) in the survey sample were free from the use of unnecessary medications.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure palatable food was served to six (of 104 residents Resident (R) 61, R36, R69, R35, R7, R87). Specifically, the food did not look appetizing and lacked flavor, the variety of menu offerings was limited, and an established recipe was not being followed correctly. This failure contributed to residents' ongoing reluctance to consume their meals, an overall dissatisfaction with their dining experience and the deviation from established recipes left residents' health and well-being at risk.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, resident interviews, record review and facility policy review the facility failed to follow the prescribed diet and honor food preferences for two (Residents (R) 69 and 35) of two residents sampled for food preferences, out of a survey sample of 35 residents. Specifically, R69 was not aware of alternate food options and had not had her food preferences updated since admission and R35 was receiving food that did not meet her taste and nutrition preferences. The failure to accommodate the residents' dietary choices and preferences violates their right to person centered care, potentially resulting in a diminished quality of life and potential negative health consequences.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on Resident interviews, staff interviews, and facility documentation review, the facility staff failed to provide snacks to Residents affecting multiple Residents on 3 of 3 nursing units.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review, it was determined the facility failed to implement a comprehensive antibiotic stewardship program. This failure had the possibility of negatively impacting all residents in the facility. In addition, the facility staff failed to follow their antibiotic stewardship program by ensuring the Resident did not receive antibiotics that were inappropriate for 2 (residents 107 and 413) of 64 sampled residents.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to afford a Resident the ability to make decisions in concerning their care for 1 of 64 residents (Resident #87), in the survey sample.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to promote and facilitate resident self-determination through support of Resident's choice, for 1 Resident in a survey sample of 64 Residents.
- 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 interviews, clinical record review and facility documentation review, the facility staff failed to ensure 1 of 64 residents (Resident #87) had an accurate medical record for an advanced directive.
- 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 observation, Resident interview, staff interview and facility documentation review, the facility staff failed to maintain a homelike environment for one Resident (Resident #32) in a survey sample of 64 Residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wrote2. For Resident #98 the facility failed to accurately assess Resident #98 in the MDS (Minimum Data Set) with an ARD (assessment reference date of 8/2/23. On 8/23/98 at approximately 9:58 AM Resident #98 was observed sitting in his wheelchair watching the TV. Resident #98 was asked about his mobility, and he stated I cannot feel my legs other than the spasms I get from my back to my legs and then from the legs down with the neuropathy pain too. When asked if he could safely transfer on and off the toilet he stated, I manage ok, some days I need more. When asked if he could walk unassisted, he stated that he could not. The Resident stated that anything involving the legs down he needed assistance with. When asked does he get the assistance he needs when he requests it, he stated that he needs help with shower because if he bends over to wash his feet, he will fall out of the shower chair. [...]
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on facility staff interviews, clinical record review and facility documentation review, the facility staff failed to incorporate the recommendations from a level II PASARR (preadmission screening and resident review) into the Resident's assessment and care planning for one Resident (Resident #10) in a survey sample of 64 Residents.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure one of seven residents (Resident (R) 91) reviewed for Preadmission Screening and Resident Review (PASARR) had a Level One PASARR completed prior to admission. This failure had the potential for R91 to not receive services necessary for mental health and psychosocial well-being.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview and record review, the facility staff failed to follow physician orders for the application of ace wraps to the bilateral lower extremities.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on Resident interview, facility staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that Residents were free from accident hazards, affecting one Resident (Resident #29) in a survey sample of 64 Residents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review, and facility documentation review, the facility staff failed to A) coordinate services to ensure she arrived at dialysis timely and B) provide meals and snacks for one (Resident #29) in a survey sample of 64 Residents.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to perform annual performance reviews for 2 (CNA's) Certified Nursing Assistants (CNA B, and CNA C) to provide regular education based upon the review outcome.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure a resident who diagnosed with mental disorder or a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment for 1 Resident (#98) in a survey sample of 64 Residents.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure 2 of 64 residents (#34 and #85) in the survey sample were free of significant medication errors.
- D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, Resident interview, staff interview and facility documentation review, the facility staff failed to provide beverages in accordance with Resident's preferences for one Resident (Resident #85) in a survey sample of 64 Residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all staff followed neutropenic precautions for one of one resident (Resident (R)163) by not donning personal protective equipment (PPE) prior to entering the R163's room. This failure had the potential of exposing R163 to an infectious disease.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review and interview the facility failed to ensure all residents received or were offered an influenza and pneumococcal vaccinations for two (Resident (R) 80 and R97) out of five sampled residents.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, Resident interview and facility staff interviews, the facility staff failed to maintain equipment in a safe operating condition for one Resident (Resident #82 ) in a survey sample of 64 Residents.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to ensure two of a sample of 64 residents (Resident (R) 27 and R81) were provided with a functional call light for use when assistance could be needed. This failure had the potential to adversely affect the timeliness of care or response time in case of an urgent or emergent need.
September 2, 2021Standard inspection · 13 citations
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure five of 49 sampled residents; Resident #62, #40, #72, #86, and 1 closed record resident; Resident #191, who were unable to carry out Activities of Daily Living (ADLs) received showers.
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, clinical record review, staff interviews and facility document review the facility staff failed to ensure that 1 of 44 residents (Resident #32) in the survey sample was provided ongoing resident centered activity services based on the resident's activity preferences from May through August of 2021.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to maintain a complete and accurate clinical record for four of 49 sampled residents, Resident #18, #1, #391 and #90.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure access to resident funds for one of 49 sampled residents; Resident #49.
- 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 ensure that the care plan or care plan goals were sent with two of 49 sampled residents at the time of an acute care transfer for Resident #62 and #18.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on observations, clinical record review, staff interviews and facility document review the facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) was conducted prior to admission or within 30 days of admission to the nursing facility for 1 of 44 residents in the survey sample, Resident #23 with diagnoses of mental disorders.
- 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 observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure an accurate oxygen therapy care plan for one of 49 sampled residents; Resident #1.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record reviews, the facility's staff failed to ensure care and services were provided to meet professional standards of quality for 2 residents (Resident #30 and Resident #1) in the survey sample. The facility staff failed to obtain a physician's order prior to use of a seat belt for Resident #30, and to obtain daily weights as ordered by the physician for Resident #1.
- 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 facility staff failed to clarify orders for the use of oxygen AND failed to follow oxygen orders for one of 49 residents in the survey sample, Resident #1.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to coordinate care with the dialysis center for one of 49 sampled residents; Resident #62.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on resident interview, staff interview, and facility document review it was determined that the facility staff failed to ensure nurses were competent in calibrating their recently acquired Blood Glucose Monitoring System (1) (glucose meter) per policy and manufacturers recommendations.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, record review and staff interviews, the facility staff failed to procure medications (hydrocortisone cream and scheduled topical pain relief medication) timely for one resident (Resident #23) in a survey sample of 49 residents.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations during medication pour and pass, staff interviews, and clinical record review, the facility's staff failed to ensure a resident didn't experience a significant medication error (blood sugar orders were duplicated and insulin was administered outside of parameters, too close to the next possible dose) for 1 of 44 residents (Resident #10), in the survey sample.
March 22, 2019Standard inspection · 12 citations
- E
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on general observations, staff, resident and group interview, the facility staff failed to ensure the resident who have authorized the facility to manage their personal funds have ready and reasonable access to those funds.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, it was determined that facility staff failed to implement abuse policies and report an allegation of abuse to the appropriate state agencies for one of 38 residents in the survey sample, Resident #75. For Resident #75, facility staff failed to implement abuse policies and report an allegation of verbal abuse reported to the administrator on 3/20/19 to the appropriate state agencies.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for one of 38 residents in the survey sample, Resident #75. For Resident #75, facility staff failed to report an allegation of verbal abuse reported to the administrator on 3/20/19 to the appropriate state agencies.
- 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 facility staff failed to evidence that all the required information was provided to the receiving provider for a facility-initiated transfer for 3 of 38 residents in the survey sample; Resident #82, #60, and #28. 1. For Resident #82, facility staff failed to send care plan goals at the time of a facility-initiated transfer to the hospital on 2/26/19. 2. The facility staff failed to ensure that Resident #60's Plan of Care Summary Goals were sent upon discharge to the hospital on [DATE], 2/6/18, and 3/2/19. 3. The facility staff failed to convey Resident #28's Individual Plan of Care summary upon discharge to the local acute care hospital on [DATE]
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review, staff interviews, and facility document review the facility staff failed to issue bed-hold notices and policy at the time of discharge for 1 of 38 residents (Resident #28) in the survey sample. The facility's staff failed to provide written information to the resident or resident representative which specifies the duration of the bed-hold policy upon transfer to the local acute care hospital on [DATE] for Resident #28.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interview and review of the facility's policy, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 38 residents (Residents #21), in the survey sample. The facility staff failed to accurately code Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE], at section N0350 (Insulin Injections).
- 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 facility staff failed to review and revise the care plan for one of 38 residents in the survey sample, Resident #98. For Resident #98, facility staff failed to revise the care plan when his code status changed to DNR (Do Not Resuscitate) and was ordered for comfort care measures.
- D
Provide appropriate foot care.
Inspectors wroteBased on observations, resident interview, clinical record review, and staff interviews, the facility staff failed to ensure residents received necessary foot care to maintain good foot health, for 1 of 38 residents (Residents #76), in the survey sample. The facility staff failed to ensure Resident #76's toe nails were not overgrown, thick and discolored.
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview it was determined that facility staff failed to dispose garbage and refuse properly for one of three facility dumpsters, the third facility dumpster. Facility staff failed to ensure one of three facility dumpsters was free from surrounding debris.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews and clinical record review the facility staff failed to ensure infection control measures were utilized to prevent the spread of infections, illnesses and diseases for 1 of 38 residents in the survey sample, Resident #51. Licensed Practical Nurse (LPN) #6 failed to don (to put on) gloves and gown (PPE/Personal Protective Equipment) before entering a contact precaution room and failed to perform proper hand hygiene after completing wound care on Resident #51.
- C
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observations, resident, group and staff interviews the facility staff failed to have ensured that the names, addresses and telephones numbers of all State resident advocacy groups and the State survey agency were legible and posted in a conspicuous place and position accessible to the facility residents. Upon the State survey and certification agency's team entrance into the facility and during the orientation tour the posting of information on the advocacy groups and State survey agency was noted to be illegible in small print and in a position on the wall and hallway inaccessible to the residents.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observations, resident, group and staff interviews it was determined that the facility staff failed to post a notice that indicated where the survey results were located for their examination without having to ask someone. The facility staff failed to ensure survey results were easily available to the resident without having to ask.
Fire safety inspections
14 fire safety citations on file: 6 on August 25, 2023, 7 on September 2, 2021, 1 on March 22, 2019.
Every fire safety citation14 citations
- E
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 · August 25, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 25, 2023 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · August 25, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 25, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · August 25, 2023 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · August 25, 2023 · Corrected (the home has a date of correction)
- E
Address patient/client population and determine types of services needed.
E 7 · September 2, 2021 · Corrected (the home has a date of correction)
- E
Establish methods for sharing information.
E 33 · September 2, 2021 · Corrected (the home has a date of correction)
- E
Provide a means of sharing information on occupancy/needs.
E 34 · September 2, 2021 · Corrected (the home has a date of correction)
- E
Provide family notifications of emergency plan.
E 35 · September 2, 2021 · Corrected (the home has a date of correction)
- E
Establish emergency prep training and testing.
E 36 · September 2, 2021 · 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 · September 2, 2021 · Corrected (the home has a date of correction)
- D
Have proper power supply for life support equipment.
K 915 · September 2, 2021 · Corrected (the home has a date of correction)
- C
Address patient/client population and determine types of services needed.
E 7 · March 22, 2019 · Corrected (the home has a date of correction)