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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
8D
0E
0F
Potential for minimal harm
0A
0B
0C
November 15, 2024Standard inspection · 5 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of facility policy, medical record review and interviews, the facility failed to provide post dialysis interventions for 1 resident (Resident #151) of 1 residents reviewed for dialysis.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on medical record review and interview, the facility failed to resubmit a timely Level I (one) Preadmission Screening and Resident Review (PASRR) for 3 residents (Resident #29, #47 and #54) of 5 residents reviewed for PASRR.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on medical record review, observation and interview, the facility failed to obtain physician orders for oxygen for 1 resident (Resident #301) of 3 residents reviewed for oxygen therapy.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of facility policy, medical record review, pharmacy delivery reports, observation and interviews, the facility failed to accurately transcribe a physician's order for 1 resident (Resident #51) of 7 residents reviewed for medication administration.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policy, medical record review, observation and interviews, the facility failed to ensure infection control practices were observed during medication administration for 1 resident (Resident #1) of 7 residents observed for medication administration and failed to ensure enhanced barrier precautions (EBP) were implemented for 1 resident (Resident # 45) of 17 residents reviewed for EBP.
February 2, 2022Standard inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide fingernail care for 1 resident (Resident #45) of 3 residents reviewed for Activities of Daily Living (ADL) Care.
March 20, 2019Standard inspection · 4 citations
- G
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 review of facility policy, medical record review, review of facility documentation, and interview the facility failed to follow the plan of care for bed mobility for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents. The facility's failure to follow the plan of care for Resident #9 resulted in actual harm.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to prevent a fall resulting in actual Harm for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of the facility policy, medical record review, and interview the facility failed to administer an ordered medication to 1 resident (#318) of 24 sampled residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to follow contact isolation precautions for 1 resident (#87) of 1 resident observed for isolation precautions of 9 halls observed for infection control.
Fire safety inspections
7 fire safety citations on file: 3 on November 15, 2024, 2 on February 2, 2022, 2 on March 20, 2019.
Every fire safety citation7 citations
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · November 15, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 2, 2022 · Corrected (the home has a date of correction)
- D
Install properly constructed and protected linen or trash chutes.
K 541 · February 2, 2022 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 20, 2019 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · March 20, 2019 · Corrected (the home has a date of correction)