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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K1 | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D42 | E28 | F23 |
| Minimal | A· | B· | C4 |
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 | |
|---|---|---|---|---|---|---|
| Aug 14, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 1, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 16, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 19, 2025 | Fire safety | Fire Safety Standard | 24 | Potential harm | — | Open → |
| Aug 19, 2025 | Health | Health Standard | 6 | Potential harm | — | Open → |
| Dec 20, 2024 | Health | Infection Control | 0 | No citations | — | Open → |
| Oct 4, 2024 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Oct 4, 2024 | Health | Health Standard | 12 | Potential harm | — | Open → |
| Aug 23, 2024 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Jul 15, 2024 | Health | Health Complaint | 4 | Immediate jeopardy | — | Open → |
| Feb 20, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 11, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Oct 12, 2023 | Health | Health Complaint | 1 | Immediate jeopardy | — | Open → |
| Aug 28, 2023 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Aug 28, 2023 | Health | Health Standard | 20 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jul 15, 2024 | Denial of payment for new admissions | — | Aug 9, 2024 · 34 days | 155219|Payment Denial|2024-08-09 |
| Jul 15, 2024 | Civil money penalty (fine) | $84,256 | — | 155219|Fine|51484 |
| Jul 15, 2024 | Civil money penalty (fine) | $16,801 | — | 155219|Fine|51455 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K1 | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D42 | E28 | F23 |
| Minimal | A· | B· | C4 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 14, 2026 | F-0627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 4, 2026 | Complaint |
| Jul 1, 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 | Corrected Jul 15, 2026 |
“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.
CMS reports the legal business name as not available.
Not part of a CMS-reported chain.
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Holy Cross Rehabilitation and Wellness 17475 Dugdale Dr, South Bend, IN 46635 CCN 155506 | 2.1 km | 168 | May 15, 2026 | 471 open | — | |
| Wellbrooke of South Bend 52565 State Road 933, South Bend, IN 46637 CCN 155824 | 3.4 km | 70 | Apr 20, 2026 | 431 harm | — | |
| Brickyard Healthcare - Fountainview Care Center 609 W Tanglewood Ln, Mishawaka, IN 46545 CCN 155178 | 4 km | 130 | Feb 23, 2026 | 61 | — | |
| Healthwin Health & Rehabilitation 20531 Darden Rd, South Bend, IN 46637 CCN 155153 | 4.1 km | 145 | Aug 17, 2026 | 781 harm1 open | — | |
| Holy Cross Village at Notre Dame Inc 54515 Sr 933 N, Notre Dame, IN 46556 CCN 155745 | 4.3 km | 52 | May 6, 2026 | 341 harm | — | |
| West Woods of Niles 1211 State Line Rd, Niles, MI 49120 CCN 235594 | 4.4 km | 121 | Jul 16, 2026 | 461 IJ4 harm2 open | $17k | |
| Belltower Health & Rehabilitation Center 5805 North Fir Road, Granger, IN 46530 CCN 155850 | 4.7 km | 96 | Oct 29, 2025 | 63 | — | |
| Creekside Village 1420 E Douglas Rd, Mishawaka, IN 46545 CCN 155784 | 4.7 km | 100 | Jul 13, 2026 | 31 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 155219 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 155219 | 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 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Jan 16, 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 | Corrected Jan 30, 2026 | Complaint |
| Jan 16, 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 Jan 30, 2026 | Complaint |
| Aug 19, 2025 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | 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. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 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. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 3, 2025 |
| Aug 19, 2025 | 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 | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | 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 3, 2025 |
| Aug 19, 2025 | 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 3, 2025 |
| Aug 19, 2025 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | 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 | D · Potential harm Isolated | Corrected Sep 29, 2025 |
| Aug 19, 2025 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 29, 2025 |
| Aug 19, 2025 | 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 | Corrected Sep 29, 2025 |
| Aug 19, 2025 | 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 Sep 29, 2025 |
| Aug 19, 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 | D · Potential harm Isolated | Corrected Sep 29, 2025 |
| Aug 19, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 29, 2025 |
| Aug 19, 2025 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Oct 3, 2025 |
| Aug 19, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Oct 3, 2025 |
| Oct 4, 2024 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 2024 | E-0032 | Provide primary/alternate means for communication. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 11, 2024 |
| Oct 4, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2024 |
| Oct 4, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 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 | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Oct 4, 2024 | 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 Nov 7, 2024 |
| Oct 4, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Oct 4, 2024 | 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 Nov 7, 2024 |
| Oct 4, 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 Nov 7, 2024 |
| Oct 4, 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 Nov 7, 2024 |
| Oct 4, 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 Nov 7, 2024 |
| Oct 4, 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 Nov 7, 2024 |
| Oct 4, 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 Nov 7, 2024 |
| Oct 4, 2024 | 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 | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Oct 4, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Oct 4, 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 | E · Potential harm Pattern | Corrected Nov 7, 2024 |
| Oct 4, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Oct 4, 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 | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Aug 23, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Sep 12, 2024 | Complaint |
| Aug 23, 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 Sep 12, 2024 | Complaint |
| Aug 23, 2024 | 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 Sep 12, 2024 | Complaint |
| Jul 15, 2024 | 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 Aug 8, 2024 | Complaint |
| Jul 15, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 12, 2024 | Complaint |
| Jul 15, 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 8, 2024 | Complaint |
| Jul 15, 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 8, 2024 | Complaint |
| Feb 20, 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 | D · Potential harm Isolated | Corrected Mar 7, 2024 | Complaint |
| Feb 20, 2024 | 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 7, 2024 | Complaint |
| Jan 11, 2024 | 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 Jan 26, 2024 | Complaint |
| Jan 11, 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 Jan 26, 2024 | Complaint |
| Oct 12, 2023 | 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 | Past non-compliance Oct 4, 2023 | Complaint |
| Aug 28, 2023 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 26, 2023 |
| Aug 28, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 26, 2023 |
| Aug 28, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted |
| Aug 28, 2023 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 26, 2023 |
| Aug 28, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 26, 2023 |
| Aug 28, 2023 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2023 |
| Aug 28, 2023 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 10, 2023 |
| Aug 28, 2023 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 26, 2023 |
| Aug 28, 2023 | 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 Nov 10, 2023 |
| Aug 28, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 26, 2023 |
| Aug 28, 2023 | F-0567 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | F-0569 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | 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 | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | 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 Sep 30, 2023 |
| Aug 28, 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 Sep 30, 2023 |
| Aug 28, 2023 | 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 | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 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 Sep 30, 2023 |
| Aug 28, 2023 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 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 Sep 30, 2023 |
| Aug 28, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | 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 Sep 30, 2023 |
| Aug 28, 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 Sep 30, 2023 |
| Aug 28, 2023 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 2023 | 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 Sep 30, 2023 |
| Aug 28, 2023 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 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 Sep 30, 2023 |
| Aug 28, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 30, 2023 |
| Aug 28, 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 Sep 30, 2023 |
| Aug 28, 2023 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 26, 2023 |
| Aug 28, 2023 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 26, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.16 (case-mix index 1.45).