| Aug 8, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Sep 16, 2025 | Complaint |
| Oct 10, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | K-0363 | Install corridor and hallway doors that block smoke. | D · Potential harm Isolated | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | K-0919 | Meet requirements for the use of electrical equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | F-0578 | 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.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0584 | 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.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0758 | 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.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0761 | 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.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Oct 31, 2024 | |
| Oct 10, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 28, 2024 | |
| Oct 10, 2024 | F-0912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Environmental Deficiencies · Environment & life safety | B · Minimal Pattern | Waiver granted Oct 31, 2024 | |
| Nov 16, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D · Potential harm Isolated | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | K-0363 | Install corridor and hallway doors that block smoke. | D · Potential harm Isolated | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | K-0919 | Meet requirements for the use of electrical equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 18, 2023 | |
| Nov 16, 2023 | F-0572 | Give residents a notice of rights, rules, services and charges.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 13, 2023 | |
| Nov 16, 2023 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 13, 2023 | |
| Nov 16, 2023 | F-0692 | Provide enough food/fluids to maintain a resident's health.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 13, 2023 | |
| Nov 16, 2023 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 13, 2023 | |
| Nov 16, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Dec 13, 2023 | |
| Mar 1, 2022 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | D · Potential harm Isolated | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0919 | Meet requirements for the use of electrical equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 20, 2022 | |
| Mar 1, 2022 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0584 | 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.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0700 | 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.Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0814 | Dispose of garbage and refuse properly.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 18, 2022 | |
| Mar 1, 2022 | F-0912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Environmental Deficiencies · Environment & life safety | B · Minimal Pattern | Corrected May 18, 2022 | |