| Apr 30, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0018 | Establish procedures for tracking staff and patients during an emergency.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0025 | Create arrangements with other facilities to receive patients.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0031 | Provide emergency officials' contact information.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0032 | Provide primary/alternate means for communication.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0033 | Establish methods for sharing information.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0034 | Provide a means of sharing information on occupancy/needs.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0035 | Provide family notifications of emergency plan.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | E-0042 | Meet the requirements of an integrated health system.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0231 | Provide large enough exits. | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0281 | Install proper backup exit lighting. | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0324 | Provide properly protected cooking facilities. | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0363 | Install corridor and hallway doors that block smoke. | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0500 | Meet other general requirements that are deficient. | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0531 | Have elevators that firefighters can control in the event of a fire. | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0911 | Meet requirements for the installation and maintenance of electrical systems.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | 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 | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | K-0915 | Have proper power supply for life support equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | 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 Jun 10, 2026 | |
| Apr 30, 2026 | 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 Jun 10, 2026 | |
| Apr 30, 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 Jun 10, 2026 | |
| Apr 30, 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 | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 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 | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | 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, 2026 | |
| Apr 30, 2026 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| Apr 30, 2026 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 10, 2026 | |
| May 8, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 19, 2025 | Complaint |
| Jul 25, 2024 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | E-0032 | Provide primary/alternate means for communication.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | E-0042 | Meet the requirements of an integrated health system.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0324 | Provide properly protected cooking facilities. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0351 | Install an approved automatic sprinkler system. | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0400 | Meet fire sprinkler requirement for tall buildings.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | K-0915 | Have proper power supply for life support equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | 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 Aug 25, 2024 | |
| Jul 25, 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 | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 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 Aug 25, 2024 | |
| Jul 25, 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 Aug 25, 2024 | |
| Jul 25, 2024 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | 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 Aug 25, 2024 | |
| Jul 25, 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 | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | 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 Aug 25, 2024 | |
| Jul 25, 2024 | 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 Aug 25, 2024 | |
| Jul 25, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 25, 2024 | |
| Jul 25, 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 Aug 25, 2024 | |
| Jul 25, 2024 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 25, 2024 | |
| Jul 25, 2024 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 25, 2024 | |
| Jul 14, 2022 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E · Potential harm Pattern | Corrected Aug 19, 2022 | |
| Jul 14, 2022 | F-0693 | 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.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 19, 2022 | |
| Jul 14, 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 | D · Potential harm Isolated | Corrected Aug 19, 2022 | |
| Jul 14, 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 | F · Potential harm Widespread | Corrected Aug 19, 2022 | |
| Jul 14, 2022 | 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 Aug 19, 2022 | |