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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
8E
0F
Potential for minimal harm
0A
0B
0C
October 28, 2024Complaint inspection · 1 citation
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure care for gastrostomy tubes was provided in accordance with professional standards for one (#2) of three residents sampled for gastrostomy tubes.
January 24, 2024Standard inspection, Complaint inspection · 12 citations
- E
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 observations, interviews, and record review the facility failed to provide a clean, sanitary, and homelike environment for residents on one unit (#300) out of three units in the facility.
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interviews and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four residents (#51, #236, #72, #115) out of six sampled residents, were revised for accuracy related to diagnoses.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II assessment for a qualifying mental health diagnosis for two residents (#6 and #97) of six residents sampled.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide treatments and care in accordance with professional standards of practice as evidence by 1) failure to assess and treat a wound for one resident (#51) out of two sampled for skin conditions, 2) failure to document and treat a change in condition according to facility policy for one resident (#82) out of two residents sampled for change in condition, and 3) failure to maintain a midline intravenous catheter as ordered for one resident (#41) out of one sampled for intravenous access.
- 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, interviews, and record review, the facility failed to ensure hydration was provided to residents residing on the secured unit in a sanitary manner during two lunch meals (1/21/24 and 1/22/24) out of two lunch meal observed.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide one resident (#109) with dignity and respect related to bowel and bladder needs out of one resident sampled for dignity.
- 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 observations, interviews, and record review the facility failed to review and revise the resident centered care plan related to behaviors for one resident (#82) of five residents sampled for comprehensive care plans.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews and record review the facility failed to provide activities of daily living (ADL) for one resident (#18) out of four residents sampled for ADL care related to personal hygiene and bathing.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide care and services according to physician's orders related to catheter care for one resident (Resident #36) out of the two sampled residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and two errors were identified for one resident (#55) of four residents observed. These errors constituted a 6.9% medication error rate.
- 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 observations, interviews and record review the facility failed to ensure all medications were secured appropriately limiting access to unauthorized persons 1) in one treatment cart (100 hall) of 3 treatment carts, and 2) leaving medications unsecured during medication administration.
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on record review and interviews the facility failed to update the facility-wide assessment to determine what staff competencies are needed for care of residents with different types of acuities.
October 22, 2021Standard inspection · 7 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to have an adequate supply of personal care supplies (urinals) for one (Resident #46) out of twenty-seven sampled residents.
- E
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 observations, record reviews, and interviews, the facility failed to ensure an adequate supply of linens (towels) for eight (Residents #46, #102, #23, #70, #62, #2, #29, and #107) out of the sampled fifty-seven residents.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record reviews and interviews, the facility failed to resolve grievances related to cold food for five (Residents #46, #102, #23, #70, and #62) out of fifty-seven sampled residents.
- 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 observations, interviews, and record review, the facility failed to ensure side effects and/or behavioral monitoring with the use of psychotropic medications for two (Resident #43 and Resident #98) of five sampled residents.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, and interview, the facility did not ensure a medication error rate of less than 5%. During the medication pass observation, there were twenty five opportunities with six errors resulting in a 24% medication error rate for two (Residents #63 and #35) of five residents observed.
- 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 policy review, the facility did not ensure that a refrigerated controlled substance was secured in a separately locked, permanently affixed container on one of three units.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observations of meals, interview with residents and facility staff, and review of the facility's menu and materials on the facility's new diet, ( IDDSI - International Dysphagia Diet Standardization Initiative), the facility failed to ensure residents who were on mechanically altered diets received foods that had been correctly prepared to follow the IDDSI guidelines and ensure the foods were safe for two (Residents #60 and #22) of 41 residents identified as having physician orders for mechanically altered diets.
February 7, 2020Standard inspection · 5 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one ( #4) of 4 residents sampled, received treatment and care in accordance with professional standards of practice related to follow up for low blood pressure readings.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure appropriate treatment and services were provided to prevent urinary tract infections (UTI) for two residents (#76 and #102) of three residents sampled for UTIs.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, record review and interviews the facility failed to ensure ongoing communication between the facility and the dialysis care center for one resident (#184) of one sampled resident of a total of three residents who received dialysis care and services.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that medications were delivered as prescribed for one resident (#120) of eight sampled residents. This resulted in medications being administered crushed in a manner that was not recommended by the manufacturer for Resident #120. These 2 errors observed during the medication administration of 25 total medications represented an error rate of 8.0%.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (#4) of 4 sampled residents, received laboratory services as ordered.
Fire safety inspections
13 fire safety citations on file: 2 on September 3, 2024, 5 on January 24, 2024, 6 on February 7, 2020.
Every fire safety citation13 citations
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 3, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 3, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 24, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 24, 2024 · Corrected (the home has a date of correction)
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 24, 2024 · Corrected (the home has a date of correction)
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · January 24, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 7, 2020 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · February 7, 2020 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · February 7, 2020 · 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 · February 7, 2020 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 7, 2020 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · February 7, 2020 · Corrected (the home has a date of correction)