| Aug 7, 2025 | 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. | D · Potential harm Isolated | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | D · Potential harm Isolated | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | K-0781 | Have restrictions on the use of portable space heaters.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | 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 | F · Potential harm Widespread | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | F-0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | 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 | F · Potential harm Widespread | Corrected Sep 19, 2025 | |
| Aug 7, 2025 | 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 Sep 19, 2025 | |
| Aug 7, 2025 | F-0923 | Have enough outside ventilation via a window or mechanical ventilation, or both.Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 19, 2025 | |
| Mar 19, 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 May 3, 2025 | Complaint |
| Mar 24, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Mar 24, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Mar 24, 2024 | K-0363 | Install corridor and hallway doors that block smoke. | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Mar 24, 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 May 8, 2024 | |
| Mar 24, 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 May 8, 2024 | |
| Mar 24, 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 | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Mar 24, 2024 | 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 | F · Potential harm Widespread | Corrected May 8, 2024 | |
| Mar 24, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Mar 24, 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 May 8, 2024 | |
| Mar 24, 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 | F · Potential harm Widespread | Corrected May 8, 2024 | |
| Mar 24, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Jan 31, 2023 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently.Administration Deficiencies · Administration & records | J · Immediate jeopardy Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | E-0022 | Establish policies and procedures for sheltering.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | E-0032 | Provide primary/alternate means for communication.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | 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. | F · Potential harm Widespread | Corrected Apr 11, 2023 | |
| Jan 31, 2023 | K-0311 | Have an enclosure around a vertical opening shaft. | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Apr 11, 2023 | |
| Jan 31, 2023 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0563 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | 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 15, 2023 | |
| Jan 31, 2023 | 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 Mar 15, 2023 | |
| Jan 31, 2023 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0791 | Provide or obtain dental services for each resident.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 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 | F · Potential harm Widespread | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | 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 15, 2023 | |
| Jan 31, 2023 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 15, 2023 | |
| Jan 31, 2023 | 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 Mar 15, 2023 | |