9 CMS Surveys
Inspection Report — Jan 22, 2025
Annual Inspection
Date: Jan 22, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility failed to identify and properly report a fall for a resident with a history of falls and did not implement the fall policy correctly. The survey found inadequate supervision and failure to complete required incident reports and assessments.
Deficiencies (1)
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to identify a fall for a resident with a history of falling and failed to implement their fall policy for 1 of 3 residents reviewed for safety and supervision.
Report Facts
Residents affected: 1
Inspection Report — Aug 8, 2024
Annual Inspection
Date: Aug 8, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity during personal care, failure to obtain weights as ordered, unsafe storage of razors accessible to residents with dementia, improper catheter care, failure to administer oxygen as ordered, medication administration issues, failure to offer bedtime snacks as ordered, and lapses in infection prevention and control practices including improper use of personal protective equipment.
Deficiencies (8)
F0550 (295.6000 Resident Rights) - The facility failed to provide dignity during personal cares for 2 of 2 residents reviewed, exposing residents during incontinence care and failing to ensure privacy curtains and doors were closed.
F0684 (295.6800 Quality of Care) - The facility failed to obtain weights as ordered by a physician for 1 of 2 residents reviewed for quality of care.
F0689 (295.6800 Safety) - The facility failed to ensure razors were removed from rooms of residents with dementia and were accessible, posing a hazard to 2 residents reviewed and others who wander.
F0690 (295.6800 Catheter Care) - The facility failed to ensure an indwelling urinary catheter drainage bag was kept below the level of the resident's bladder for 1 of 4 residents reviewed.
F0695 (295.6800 Oxygen Therapy) - The facility failed to administer oxygen as ordered by a physician for 3 of 4 residents reviewed for oxygen therapy.
F0755 (295.6800 Medication Administration) - The facility failed to ensure physician prescribed medications were administered as ordered for 1 of 2 residents reviewed for medication administration.
F0809 (295.6800 Nutrition) - The facility failed to ensure bedtime snacks were offered to residents for 3 of 3 residents reviewed and one additional resident outside the sample.
F0880 (295.6800 Infection Control) - The facility failed to implement contact isolation precautions for a resident with MRSA, failed to wear appropriate PPE for residents on enhanced barrier precautions, and failed to perform glove changes during incontinence care for 1 resident.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 4
Residents affected: 4
Inspection Report — May 14, 2024
Date: May 14, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, the inspection type is classified as 'other'.
Findings
The facility failed to ensure timely assessment and treatment of a resident's scalp eczema, affecting one of six residents reviewed. The resident's condition worsened over several months without appropriate intervention until recently.
Deficiencies (1)
F0684 (Provide appropriate treatment and care) - The facility failed to ensure a resident with eczema was assessed and treated in a timely manner, as evidenced by the worsening scalp condition of one resident over several months without proper treatment.
Report Facts
Residents affected: 1
Residents reviewed: 6
Inspection Report — Jan 11, 2024
Date: Jan 11, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to provide oxygen therapy according to professional standards for one resident experiencing low oxygen levels. The resident was not placed on the appropriate oxygen flow rate as ordered, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
F0695 (Oxygen Therapy) - The facility failed to provide safe and appropriate respiratory care by not administering oxygen at the proper flow rate for a resident in respiratory distress, resulting in inadequate oxygenation.
Report Facts
Residents affected: 1
Residents reviewed: 3
Sample size: 4
Inspection Report — Nov 2, 2023
Date: Nov 2, 2023
Visit Reason
No explicit Initial Comment block naming the visit type was found; the document is a Statement of Deficiencies for a nursing home.
Findings
The facility failed to supervise a resident with dementia and a history of wandering, resulting in bruises and injuries to the resident. The injuries were unwitnessed and the facility lacked 1:1 monitoring during the incident.
Deficiencies (1)
F0689 - The facility failed to provide adequate supervision to prevent accidents for one resident with dementia and a history of wandering, resulting in bruises and injuries.
Report Facts
Residents affected: 1
Inspection Report — Jun 28, 2023
Annual Inspection
Date: Jun 28, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and homelike environment, inadequate care for residents with pressure ulcers and incontinence, failure to provide proper nutritional supplements, and improper handling of cookware. Corrective actions are required to address these issues to ensure resident safety and care quality.
Deficiencies (7)
F0584 (295.0584) - The facility failed to ensure resident rooms were clean and homelike for 4 of 32 residents reviewed, with issues such as dirty floors, holes in walls, and inadequate housekeeping.
F0677 (295.0677) - The facility failed to provide care and assistance for activities of daily living, including incontinent care and proper positioning during meals for 2 of 32 residents reviewed.
F0686 (295.0686) - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 2 of 5 residents reviewed, including lack of off-loading interventions and treatment for open wounds.
F0689 (295.0689) - The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents for 2 of 32 residents reviewed, including failure to maintain aspiration precautions and fall interventions.
F0690 (295.0690) - The facility failed to provide appropriate perineal care to prevent infections for 1 of 9 residents reviewed, including improper cleansing technique during incontinence care.
F0692 (295.0692) - The facility failed to provide enough food/fluids to maintain a resident's health for 1 of 12 residents reviewed, by not providing ordered nutritional supplements at meals.
F0812 (295.0812) - The facility failed to procure food from approved sources and handle cookware in a sanitary manner, risking contamination for all 163 residents.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 163
Inspection Report — Apr 10, 2023
Annual Inspection
Date: Apr 10, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies related to cleanliness, maintenance, and medication administration. Eleven residents' rooms were not maintained in a clean and homelike condition, and one resident's medication administration was not properly ensured.
Deficiencies (2)
F0584 (295.XXXX) - The facility failed to ensure resident rooms were clean and repairs were performed in a timely manner for 11 of 13 residents reviewed, including broken siderails, unclean floors, and damaged walls.
F0755 (295.XXXX) - The facility failed to ensure prescription medications were administered according to standards of practice for 1 of 3 residents reviewed, as two unidentified pills were found on the floor next to the resident's bed.
Report Facts
Residents affected: 11
Residents affected: 1
Inspection Report — Feb 14, 2023
Date: Feb 14, 2023
Visit Reason
No Initial Comment block found specifying visit type; no violations cited.
Findings
No health deficiencies found; the establishment was found in compliance.
Inspection Report — Apr 6, 2022
Date: Apr 6, 2022
Visit Reason
No Initial Comment block naming the visit type was found in the document; inspection type is classified as 'other'.
Findings
The facility was cited for multiple deficiencies including failure to change wound dressings as ordered, inadequate incontinence care, improper medication dispensing and storage, failure to provide properly pureed food, and lapses in infection control practices.
Deficiencies (6)
F0684 - The facility failed to change a non-pressure wound dressing as ordered by the physician for 1 of 3 residents reviewed.
F0690 - The facility failed to provide incontinence care in a manner to prevent infection to 1 of 3 residents reviewed.
F0755 - The facility failed to ensure medications were dispensed according to standards of practice for 1 of 4 residents reviewed.
F0761 - The facility failed to ensure medications were secured for 2 of 35 residents reviewed.
F0805 - The facility failed to ensure the noon meal was thoroughly pureed for 21 of 21 residents reviewed.
F0880 - The facility failed to wash hands and change gloves to prevent the spread of infection to 1 of 35 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 21
Residents affected: 1
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