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 30 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
6E
0F
Potential for minimal harm
0A
1B
0C
December 4, 2024Standard inspection, Complaint inspection · 10 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on review of facility documentation and interviews, the facility failed to provide staff support to ensure the residents right to organize and participate in resident groups (resident council) was honored.
- E
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 review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #14, 174, 175, and 176) reviewed for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops), the facility failed to ensure that code status was reviewed with the resident or resident representative, upon admission and as needed, to ensure the residents choices were was honored.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that hot and cold food temperatures for meals were obtained and documented appropriately.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #8) reviewed for unnecessary medications, the facility failed to immediately notify the hospice provider and the resident representative when the resident had complaints of new severe wrist pain.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 8) reviewed for unnecessary medications, the facility failed to notify the state agency, according to established timeframes, when the resident complained of new severe wrist pain of unknown origin.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 8) reviewed for unnecessary medications, the facility failed to investigate an injury of unknown origin.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #10) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to notify the appropriate state-designated authority that the resident had a new diagnosis of psychotic disorder with delusions.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 5 residents (Resident #20, 12, 3, 8 and 124) the facility failed to ensure the residents received treatment and care in accordance with professional standards and physicians orders. For Resident #20, reviewed for edema, the facility failed to ensure that weights, ordered to be obtained every other day were consistently obtained. For Resident #12, the facility failed to follow the physician's order to apply compression stockings daily. For 1 of 4 residents (Resident #3), reviewed for accidents, the facility failed to ensure that neurological checks and post fall assessments were completed after the resident had multiple unwitnessed falls with reported head strikes. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #1), reviewed for accidents, the facility failed to ensure the resident was transferred according to the physician's order (Sara lift with 2 staff) which resulted in the resident having to be lowered to the floor.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 8) reviewed for unnecessary medications, the facility failed to assess and manage complaints of new severe wrist pain.
September 7, 2022Standard inspection · 7 citations
- E
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 review of facility documentation, and interviews the facility failed to ensure that nursing staff (license nurses and nurse aides) possessed the competencies and skill sets necessary to provide nurse care for residents' needs.
- D
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 the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #15) reviewed for accidents, the facility failed to implement the comprehensive care plan for a resident who was at risk for falls and subsequently sustained a fall while attempting to reach for his/her shoes which were identified in the care plan to be in the closet and out of sight.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #20) reviewed for pressure ulcers, the facility to communicate and coordinate care of a newly identified skin condition with the end of life care service provider.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #20) reviewed for pressure ulcers, the facility to ensure an RN assessment was completed when a new pressure ulcer was identified.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #15) reviewed for accidents, the facility failed to implement the care plan to prevent a fall.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview the kitchen staff failed to perform hand hygiene after touching the trash bin and failed to ensure that ice was stored under sanitary conditions.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #176) reviewed for infections, the facility failed to utilize personal protective equipment (PPE) appropriately for a resident on Transmission Based Precautions, and the facility failed to ensure that 2 staff were appropriately screened for COVID-19 symptoms prior to starting to care for residents.
September 19, 2019Standard inspection · 13 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 wroteBased on clinical record review, review of facility documentation, and interviews, for two of five residents reviewed for unnecessary medications (Residents #3 and #198), the facility failed to ensure orthostatic blood pressure monitoring was completed with the use of an antipsychotic medication and/or per physician's orders.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to ensure that outdated food items were discarded from the walk in refrigerator.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on clinical record review, review of facility documentation, interviews, and policy review for one of two sampled residents (Resident #18) who was reviewed for an allegation of mistreatment, the facility failed to ensure resident's rights to privacy and confidentiality were not violated.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on clinical record review, review of facility documentation, interviews and policy review for one of two sampled residents (Resident #18) reviewed for an allegation of mistreatment, the facility failed to ensure Resident (R) #18 was free from mental abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews, review of the clinical record, and review of facility documentation, for one of two residents reviewed for abuse, (Resident #4), the facility failed to report an allegation of abuse/mistreatment to the state agency.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews, review of the clinical record, and review of facility documentation, for one of two residents reviewed for abuse, (Resident #4), the facility lacked documentation that a thorough investigation was completed following an allegation of mistreatment.
- D
Provide care by qualified persons according to each resident's written plan of care.
Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #18) who was dependent on two staff members for transfers in and/or out of the bed and/or chair, the facility failed to ensure the appropriate number of staff were present during a Hoyer lift transfer from bed to a shower chair.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for one of two sampled residents (Resident #247) who were reviewed for accidents, the facility failed to review and/or revise the plan of care after the resident sustained a fall resulting in an injury.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on clinical record review, observation and interview for one of three sampled residents (Resident #45) reviewed for nutrition, the facility failed to ensure that baseline weights were obtained and/or failed to follow their weight policy/protocol for obtaining weights.
- 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 review of the clinical record, review of facility documentation, and interviews for one of five residents (Resident #198) reviewed for unnecessary medications and/or antipsychotic medication use, the pharmacy failed to report an irregularity regarding orthostatic blood pressures.
- 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 observation, interview, and review of facility documentation, for one of two units observed, East Rock unit, the facility failed to ensure the medication cart and treatment cart were locked when the staff was not in view of the carts.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of the clinical records, interviews, and review of facility documentation, for one of five residents reviewed for infection control/immunizations, (Resident #3), the facility failed to offer the resident the pneumococcal vaccination in a timely manner.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on review of the clinical record, review of facility documentation, and interview , for eighteen sampled Residents reviewed for Resident Assessment, (Residents #1, #11, #13, #15, #23, #30, #31, #32, #34, #39, #44, #147, #148, #149, #150, #151, #152, and #198) the facility failed to ensure the Minimum Data Set (MDS) assessment was submitted/transmitted timely.
Fire safety inspections
9 fire safety citations on file: 1 on December 4, 2024, 5 on September 7, 2022, 3 on September 19, 2019.
Every fire safety citation9 citations
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 4, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 7, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · September 7, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 7, 2022 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 500 · September 7, 2022 · Corrected (the home has a date of correction)
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · September 7, 2022 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · September 19, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 19, 2019 · Corrected (the home has a date of correction)
- D
Install properly constructed windows in hallway walls or doors.
K 364 · September 19, 2019 · Corrected (the home has a date of correction)