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 18 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
12D
0E
2F
Potential for minimal harm
0A
0B
0C
May 24, 2024Complaint inspection · 3 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by a family member for 1 of 8 (Resident #2) sampled residents reviewed for abuse . Resident #2, a vulnerable and severely cognitively impaired resident, was observed being mentally and physically abused by Family member #2 on 4/23/2024. The facility's failure to protect the resident's right to be free from physical and verbal abuse placed Resident #2 and other residents in the facility in an Immediate Jeopardy (IJ) situation, (A condition in which facility noncompliance with one or more conditions of participation has resulted in or is likely to result in serious injury, harm, impairment, or death to a resident and must be immediately corrected). [...]
- J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interview, the facility failed to report an allegation of abuse to the appropriate agencies within the required timeframe for 1 of 8 (Resident #2) sampled residents reviewed for abuse. Resident #2, a vulnerable and severely cognitively impaired resident, was observed being mentally and physically abused by Family member #2 on 4/23/2024. The facility's failure to report an allegation of abuse placed Resident #2 and other residents in the facility in an Immediate Jeopardy (IJ) situation, (A condition in which facility noncompliance with one or more conditions of participation has resulted in or is likely to result in serious injury, harm, impairment, or death to a resident and must be immediately corrected). [...]
- J
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, and interviews, the facility failed to develop a comprehensive care plan and implement appropriate interventions for 1 of 4 (Resident #2) sampled residents reviewed for care plans. On 4/23/2024, Resident #2's family member was observed being verbally and physically abusive toward Resident #2 and the facility failed to develop interventions to ensure Resident #2 was safe and monitored for his psychosocial wellbeing, latent injuries, and ensure all staff members were aware Family member #2 was not allowed in the facility following an abuse incident by a Family member. [...]
February 22, 2024Standard inspection · 5 citations
- 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, observation and interview, the facility failed to prevent accidents related to falls for 1 resident (Resident #45) of 5 residents reviewed for falls when effective and appropriate interventions to prevent falls were not implemented which resulted in actual harm to Resident #45.
- F
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on medical record review, observation and interview, the facility failed to complete side (bed) rail assessments for the risk of entrapment and failed to obtain consents for side rails for 6 residents (Residents #1, #34 #5, #23, #25 and #45) of 6 residents reviewed for side rails.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on policy review, review of prior survey results, medical record review, facility documentation review, observation and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to take effective actions plans to ensure appropriate interventions were put into place, and to monitor the effectiveness for falls for 1 resident (Resident #45) of 5 residents reviewed for falls.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on facility policy review, document review, medical record review, observation, and interview, the facility failed to ensure medical information was not visible for 5 residents (Residents #1, #3, #4, #22, and #46) of 55 residents observed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to offer hand hygiene assistance to residents prior to meals for 3 residents (Resident #44, #156, and #157) of 3 residents observed on 1 of 3 hallways observed for meal tray distribution.
June 30, 2021Standard inspection · 3 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) performed care within the scope of practice when she handed 1 resident (Resident #32) a cup of medications for the resident to take of 50 residents observed during the initial tour of the facility.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to maintain proper infection control procedures during a dressing change for 1 resident (Resident #32) of 2 residents reviewed for dressing change.
- 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 facility policy review, observation and interview, the facility failed to store a medication at the proper temperature in 1 of 3 medication carts and failed to dispose of expired medications and supplies available for resident use in 1 of 2 medication storage rooms.
February 12, 2019Standard inspection · 7 citations
- D
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on medical record review, review of the Minimum Data Set (MDS), and interview, the facility failed to complete a quarterly assessment for 1 resident (#2) of 16 residents reviewed for MDS of 16 sampled residents.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on medical record review and interview the facility failed to implement a baseline care plan for 1 resident (#148) related to vision impairment of 16 residents sampled.
- D
Post nurse staffing information every day.
Inspectors wroteBased on facility policy, observation, and interview the facility failed to complete and post the direct care daily staffing roster for 1 of 3 staffing rosters posted for 2-10-19.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on facility policy review, observation and interview, the facility failed to ensure expired over the counter medications were not available for resident use in 1 medication storage room of 2 medication storage rooms observed.
- 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 facility policy review, medical record review, and interview, the facility failed to act on a pharmacy recommendation with a rationale for declining the recommendation for 1 resident (#20) of 5 residents reviewed for unnecessary medications, of 16 residents reviewed.
- 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 wroteBased on medical record review, and interview, the facility failed to provide an evaluation and rationale for the continued use of an as needed (PRN) antianxiety medication beyond 14 days for 1 Resident (#44) of 5 residents reviewed for unnecessary medications of 16 residents sampled.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation and interview, the facility failed to properly store laboratory specimens and medications separately in 1 medication refrigerator in 1 medication storage room of 2 medication storage rooms and refrigerators observed.
Fire safety inspections
6 fire safety citations on file: 2 on June 30, 2021, 4 on February 12, 2019.
Every fire safety citation6 citations
- D
Establish an Emergency Preparedness Program (EP).
E 1 · June 30, 2021 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · June 30, 2021 · Corrected (the home has a date of correction)
- D
Establish policies and procedures for volunteers.
E 24 · February 12, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · February 12, 2019 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · February 12, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 12, 2019 · Corrected (the home has a date of correction)