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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D57 | E39 | F12 |
| Minimal | A· | B6 | C1 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Mar 25, 2026 | Health | Health Complaint | 2 | Potential harm | 2 | Open → |
| Mar 9, 2026 | Health | Health Complaint | 1 | Potential harm | 1 | Open → |
| Mar 3, 2026 | Health | Health Complaint | 6 | Potential harm | 6 | Open → |
| Feb 13, 2026 | Health | Health Complaint | 11 | Immediate jeopardy | 11 | Open → |
| Jan 13, 2026 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Jan 13, 2026 | Health | Health Standard | 26 | Actual harm | 26 | Open → |
| Nov 4, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 14, 2025 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Dec 11, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Aug 21, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Apr 29, 2024 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Apr 29, 2024 | Health | Health Complaint, Health Standard | 20 | Potential harm | — | Open → |
| Dec 28, 2021 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Dec 28, 2021 | Health | Health Standard | 27 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jan 13, 2026 | Civil money penalty (fine) | $57,715 | — | 075358|Fine|137400 |
| Mar 14, 2025 | Civil money penalty (fine) | $55,632 | — | 075358|Fine|5588 |
| Dec 11, 2024 | Civil money penalty (fine) | $8,991 | — | 075358|Fine|5568 |
| Apr 29, 2024 | Denial of payment for new admissions | — | Jul 29, 2024 · 71 days | 075358|Payment Denial|2024-07-29 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D57 | E39 | F12 |
| Minimal | A· | B6 | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Mar 25, 2026 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified May 6, 2026 | Complaint |
| Mar 25, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: — (case-mix index —).
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Newport Bickford Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 1996 |
| George Donahue | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2021 |
| Louis Galli | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2022 |
| Elaine Madden | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2021 |
| Kyle Moseley | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2022 |
| Kyle Moseley | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Jan 31, 2020 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Touchpoints at Chestnut 171 Main St, East Windsor, CT 06088 CCN 075436 | 0.7 km | 57 | Aug 18, 2025 | 47 | — | |
| Fresh River Healthcare 96 Prospect Hill Rd, East Windsor, CT 06088 CCN 075359 | 1.7 km | 134 | Aug 13, 2025 | 47 | — | |
| St Joseph's Residence 1365 Enfield St, Enfield, CT 06082 CCN 075272 | 5.9 km | 25 | Mar 27, 2025 | 6 | — | |
| Autumn Lake Healthcare at Windsor 581 Poquonock Ave, Windsor, CT 06095 CCN 075011Abuse icon | 6.7 km | 108 | Apr 14, 2026 | 911 harm | $131k | |
| Suffield House Rehabilitation and Healthcare Cente 1 Canal Road, Suffield, CT 06078 CCN 075347 | 6.8 km | 128 | Jul 29, 2026 | 341 harm | — | |
| Parkway Pavilion Health and Rehabilitation Center 1157 Enfield Street, Enfield, CT 06082 CCN 075195 | 7.3 km | 130 | Aug 28, 2026 | 891 harm1 open | — | |
| Complete Care at Kimberly Hall-South 1 Emerson Drive, Windsor, CT 06095 CCN 075237 | 10.2 km | 180 | Jul 7, 2026 | 471 IJ3 open | $15k | |
| Complete Care at Kimberly Hall North 1 Emerson Dr, Windsor, CT 06095 CCN 075279Abuse icon | 10.2 km | 150 | Jul 17, 2026 | 592 IJ3 harm | $13k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 075358 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 075358 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 075358 | county_fips County assigned by locating CMS coordinates in Census county boundaries (the CMS county name did not match the Census code list). | Inferred | Oct 1, 2026 | Nov 7, 2026 |
| Connecticut Nursing Facility Registry CT | 2178C | state_license, licensed_beds, licensee Linked to the CMS record by exact CCN. | Verified | Apr 30, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Complaint |
| Mar 9, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Apr 20, 2026 | Complaint |
| Mar 3, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Apr 14, 2026 | Complaint |
| Mar 3, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Apr 14, 2026 | Complaint |
| Mar 3, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Apr 14, 2026 | Complaint |
| Mar 3, 2026 | F-0841 | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Plan of correction, not yet verified Apr 14, 2026 | Complaint |
| Mar 3, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Apr 14, 2026 | Complaint |
| Mar 3, 2026 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Plan of correction, not yet verified Apr 14, 2026 | Complaint |
| Feb 13, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Plan of correction, not yet verified Mar 27, 2026 | Complaint |
| Feb 13, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Plan of correction, not yet verified Mar 27, 2026 | Complaint |
| Feb 13, 2026 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Plan of correction, not yet verified Mar 27, 2026 | Complaint |
| Feb 13, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Mar 27, 2026 | Complaint |
| Feb 13, 2026 | F-0772 | Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Plan of correction, not yet verified Mar 17, 2026 | Complaint |
| Feb 13, 2026 | F-0776 | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Plan of correction, not yet verified Mar 17, 2026 | Complaint |
| Feb 13, 2026 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Plan of correction, not yet verified Mar 17, 2026 | Complaint |
| Feb 13, 2026 | F-0837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Plan of correction, not yet verified Mar 17, 2026 | Complaint |
| Feb 13, 2026 | F-0841 | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Plan of correction, not yet verified Mar 17, 2026 | Complaint |
| Feb 13, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Plan of correction, not yet verified Mar 27, 2026 | Complaint |
| Feb 13, 2026 | F-0843 | Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Plan of correction, not yet verified Mar 17, 2026 | Complaint |
| Jan 13, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | No plan of correction |
| Jan 13, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 25, 2026 |
| Jan 13, 2026 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 25, 2026 |
| Jan 13, 2026 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 25, 2026 |
| Jan 13, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 25, 2026 |
| Jan 13, 2026 | 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 | No plan of correction |
| Jan 13, 2026 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | 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 | E · Potential harm Pattern | No plan of correction |
| Jan 13, 2026 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | No plan of correction |
| Jan 13, 2026 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | 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 | No plan of correction |
| Jan 13, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | No plan of correction |
| Jan 13, 2026 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | 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 | E · Potential harm Pattern | No plan of correction |
| Jan 13, 2026 | 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 | E · Potential harm Pattern | No plan of correction |
| Jan 13, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | No plan of correction |
| Jan 13, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | No plan of correction |
| Jan 13, 2026 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | No plan of correction |
| Jan 13, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | B · Minimal Pattern | No plan of correction |
| Jan 13, 2026 | F-0637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Clinical care | B · Minimal Pattern | No plan of correction |
| Jan 13, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | B · Minimal Pattern | No plan of correction |
| Jan 13, 2026 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | B · Minimal Pattern | No plan of correction |
| Jan 13, 2026 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | B · Minimal Pattern | No plan of correction |
| Jan 13, 2026 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | B · Minimal Pattern | No plan of correction |
| Nov 4, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 2, 2025 | Complaint |
| Mar 14, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected May 22, 2025 | Complaint |
| Mar 14, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 22, 2025 | Complaint |
| Mar 14, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 22, 2025 | Complaint |
| Dec 11, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 3, 2025 | Complaint |
| Aug 21, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 13, 2024 | Complaint |
| Aug 21, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 13, 2024 | Complaint |
| Apr 29, 2024 | K-0100 | Meet other general requirements. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 8, 2024 |
| Apr 29, 2024 | K-0200 | Meet other general requirements. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 8, 2024 |
| Apr 29, 2024 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 8, 2024 |
| Apr 29, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 8, 2024 |
| Apr 29, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 12, 2024 |
| Apr 29, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 10, 2024 |
| Apr 29, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 30, 2024 |
| Apr 29, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 8, 2024 |
| Apr 29, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 8, 2024 |
| Apr 29, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 24, 2024 |
| Apr 29, 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 | D · Potential harm Isolated | Corrected May 15, 2024 |
| Apr 29, 2024 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 24, 2024 |
| Apr 29, 2024 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 10, 2024 |
| Apr 29, 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 | D · Potential harm Isolated | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0585 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 10, 2024 | Complaint |
| Apr 29, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 10, 2024 | Complaint |
| Apr 29, 2024 | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jun 10, 2024 | Complaint |
| Apr 29, 2024 | 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 | F · Potential harm Widespread | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 10, 2024 |
| Apr 29, 2024 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Jun 10, 2024 | Complaint |
| Dec 28, 2021 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Mar 1, 2022 |
| Dec 28, 2021 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 1, 2022 |
| Dec 28, 2021 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 1, 2022 |
| Dec 28, 2021 | 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 Mar 1, 2022 |
| Dec 28, 2021 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 15, 2022 |
| Dec 28, 2021 | 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 Mar 17, 2022 |
| Dec 28, 2021 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0711 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0726 | 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. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0729 | Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | 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 | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | 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 | D · Potential harm Isolated | Corrected Mar 17, 2022 |
| Dec 28, 2021 | 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 Mar 17, 2022 |
| Dec 28, 2021 | F-0837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0838 | 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. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0885 | Report COVID19 data to residents and families. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0886 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 17, 2022 |
| Dec 28, 2021 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | C · Minimal Widespread | Corrected Mar 17, 2022 |