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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D66 | E30 | F39 |
| Minimal | A· | B· | C11 |
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 | |
|---|---|---|---|---|---|---|
| Jul 24, 2026 | Health | Health Complaint | 4 | Immediate jeopardy | 4 | Open → |
| Jul 1, 2026 | Fire safety | Fire Safety Complaint | 2 | Potential harm | — | Open → |
| Jun 12, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 2, 2026 | Health | Health Complaint | 4 | Actual harm | — | Open → |
| Feb 3, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 7, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Sep 10, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 23, 2025 | Fire safety | Fire Safety Standard | 21 | Potential harm | — | Open → |
| Jan 23, 2025 | Health | Health Complaint, Health Standard | 11 | Potential harm | — | Open → |
| Nov 14, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Sep 12, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Aug 16, 2024 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Aug 1, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 2, 2024 | Fire safety | Fire Safety Standard | 9 | Potential harm | — | Open → |
| Mar 2, 2024 | Health | Health Complaint, Health Standard | 29 | Actual harm | — | Open → |
| Jan 4, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 23, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 18, 2023 | Fire safety | Fire Safety Standard | 34 | Potential harm | — | Open → |
| Jan 18, 2023 | Health | Health Standard | 16 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 2, 2024 | Denial of payment for new admissions | — | Apr 2, 2024 · 14 days | 155689|Payment Denial|2024-04-02 |
| Mar 2, 2024 | Civil money penalty (fine) | $8,018 | — | 155689|Fine|51390 |
| Mar 2, 2024 | Civil money penalty (fine) | $8,018 | — | 155689|Fine|51391 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D66 | E30 | F39 |
| Minimal | A· | B· | C11 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 24, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Plan of correction, not yet verified Aug 21, 2026 | Complaint |
| Jul 24, 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 | E · Potential harm Pattern |
“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 |
|---|---|---|---|---|---|---|
| Greencroft Healthcare 1225 Greencroft Dr, Goshen, IN 46527 CCN 155205 | 1.7 km | 214 | Dec 23, 2025 | 672 harm | — | |
| Waterford Crossing 1332 Waterford Cir, Goshen, IN 46526 CCN 155760 | 2.9 km | 87 | Mar 23, 2026 | 22 | — | |
| The Restoracy of Goshen 1510 Sandpiper Ln, Goshen, IN 46526 CCN 155856 | 4.9 km | 48 | Aug 27, 2025 | 62 | — | |
| The Waters of Syracuse Skilled Nursing Facility 500 E Pickwick Dr, Syracuse, IN 46567 CCN 155581 | 17.5 km | 66 | May 21, 2026 | 512 harm | — | |
| Avalon Village 200 Kingston Cir, Ligonier, IN 46767 CCN 155286 | 19.3 km | 67 | Feb 25, 2026 | 32 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 155689 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 155689 | 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
| Plan of correction, not yet verified Aug 21, 2026 |
| Complaint |
| Jul 24, 2026 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Plan of correction, not yet verified Aug 21, 2026 | Complaint |
| Jul 24, 2026 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Plan of correction, not yet verified Aug 21, 2026 | Complaint |
| Jul 1, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 17, 2026 | Complaint |
| Jul 1, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 17, 2026 | Complaint |
| Jun 12, 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 28, 2026 | Complaint |
| Jun 2, 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 | G · Actual harm Isolated | Corrected Jun 23, 2026 | Complaint |
| Jun 2, 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 Jun 23, 2026 | Complaint |
| Jun 2, 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 | Corrected Jun 23, 2026 | Complaint |
| Jun 2, 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 | D · Potential harm Isolated | Corrected Jun 23, 2026 | Complaint |
| Feb 3, 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 | Corrected Feb 25, 2026 | Complaint |
| Feb 3, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 25, 2026 | Complaint |
| Jan 7, 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 | Corrected Jan 20, 2026 | Complaint |
| Jan 7, 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 Jan 20, 2026 | Complaint |
| Jan 7, 2026 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 20, 2026 | Complaint |
| Sep 10, 2025 | 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 Oct 1, 2025 | Complaint |
| Jan 23, 2025 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0500 | Meet other general requirements that are deficient. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 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 Mar 14, 2025 |
| Jan 23, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 14, 2025 |
| Jan 23, 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 Feb 12, 2025 |
| Jan 23, 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 | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 2025 | F-0646 | Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 2025 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 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 | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 2025 | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Feb 12, 2025 |
| Jan 23, 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 Feb 12, 2025 |
| Jan 23, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 12, 2025 | Complaint |
| Nov 14, 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 30, 2024 | Complaint |
| Nov 14, 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 Nov 30, 2024 | Complaint |
| Nov 14, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 30, 2024 | Complaint |
| Sep 12, 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 27, 2024 | Complaint |
| Sep 12, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 27, 2024 | Complaint |
| Sep 12, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 27, 2024 | Complaint |
| Aug 16, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 9, 2024 | Complaint |
| Aug 16, 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 Sep 9, 2024 | Complaint |
| Aug 16, 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 Sep 9, 2024 | Complaint |
| Aug 16, 2024 | F-0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 9, 2024 | Complaint |
| Aug 1, 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 Aug 13, 2024 | Complaint |
| Mar 2, 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 | G · Actual harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 16, 2024 |
| Mar 2, 2024 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 28, 2024 |
| Mar 2, 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. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 28, 2024 |
| Mar 2, 2024 | 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 Apr 28, 2024 |
| Mar 2, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 28, 2024 |
| Mar 2, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 28, 2024 |
| Mar 2, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 28, 2024 |
| Mar 2, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 28, 2024 |
| Mar 2, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 28, 2024 |
| Mar 2, 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 Apr 28, 2024 |
| Mar 2, 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 Mar 22, 2024 | Complaint |
| Mar 2, 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 22, 2024 |
| Mar 2, 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 22, 2024 |
| Mar 2, 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 Mar 22, 2024 |
| Mar 2, 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 Mar 22, 2024 |
| Mar 2, 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 Mar 22, 2024 |
| Mar 2, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 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 Mar 22, 2024 |
| Mar 2, 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 | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 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 Mar 22, 2024 | Complaint |
| Mar 2, 2024 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | 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 Mar 22, 2024 |
| Mar 2, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | 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 Mar 22, 2024 |
| Mar 2, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 22, 2024 | Complaint |
| Mar 2, 2024 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 22, 2024 | Complaint |
| Mar 2, 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 Mar 22, 2024 |
| Mar 2, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 22, 2024 |
| Mar 2, 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 Mar 22, 2024 |
| Mar 2, 2024 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Mar 22, 2024 |
| Jan 4, 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 Jan 12, 2024 | Complaint |
| Oct 23, 2023 | 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 Nov 3, 2023 | Complaint |
| Jan 18, 2023 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0022 | Establish policies and procedures for sheltering. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0029 | Develop a communication plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | 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 Mar 25, 2023 |
| Jan 18, 2023 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 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 Apr 11, 2023 |
| Jan 18, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 25, 2023 |
| Jan 18, 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 Mar 25, 2023 |
| Jan 18, 2023 | K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 25, 2023 |
| Jan 18, 2023 | 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 Feb 10, 2023 |
| Jan 18, 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 Feb 10, 2023 |
| Jan 18, 2023 | 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 Feb 10, 2023 |
| Jan 18, 2023 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 10, 2023 |
| Jan 18, 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 | E · Potential harm Pattern | Corrected Feb 10, 2023 |
| Jan 18, 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 | E · Potential harm Pattern | Corrected Feb 10, 2023 |
| Jan 18, 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 | E · Potential harm Pattern | Corrected Feb 10, 2023 |
| Jan 18, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 10, 2023 |
| Jan 18, 2023 | 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 Feb 10, 2023 |
| Jan 18, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 10, 2023 |
| Jan 18, 2023 | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 10, 2023 |
| Jan 18, 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 Feb 10, 2023 |
| Jan 18, 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 Feb 10, 2023 |
| Jan 18, 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 | D · Potential harm Isolated | Corrected Feb 10, 2023 |
| Jan 18, 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 Feb 10, 2023 |
| Jan 18, 2023 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0032 | Provide primary/alternate means for communication. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0033 | Establish methods for sharing information. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0034 | Provide a means of sharing information on occupancy/needs. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 2023 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 25, 2023 |
| Jan 18, 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 Mar 25, 2023 |
| Jan 18, 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 Mar 25, 2023 |
| Jan 18, 2023 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Mar 25, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 2.74 (case-mix index 1.58).