| Feb 17, 2026 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | K · Immediate jeopardy Pattern | Corrected Mar 9, 2026 | |
| Feb 17, 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 | G · Actual harm Isolated | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 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 | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | 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 9, 2026 | |
| Feb 17, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | 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 Mar 9, 2026 | |
| Feb 17, 2026 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | 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 Mar 9, 2026 | |
| Feb 17, 2026 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | 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 | F · Potential harm Widespread | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 9, 2026 | |
| Feb 17, 2026 | 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 9, 2026 | |
| Feb 17, 2026 | K-0300 | Meet other general requirements that are deficient. | C · Minimal Widespread | Corrected Mar 9, 2026 | |
| Sep 16, 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 | J · Immediate jeopardy Isolated | Corrected Sep 17, 2025 | Complaint |
| Mar 25, 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 Apr 18, 2025 | Complaint |
| Mar 25, 2025 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Apr 18, 2025 | Complaint |
| Nov 14, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Dec 13, 2024 | |
| Nov 14, 2024 | K-0300 | Meet other general requirements that are deficient. | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0500 | Meet other general requirements that are deficient. | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 6, 2025 | |
| Nov 14, 2024 | F-0635 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 13, 2024 | |
| Nov 14, 2024 | 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 Dec 13, 2024 | |
| Nov 14, 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 Dec 13, 2024 | |
| Nov 14, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 13, 2024 | |
| Nov 14, 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 Dec 13, 2024 | |
| Nov 14, 2024 | F-0728 | Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Dec 13, 2024 | |
| Nov 14, 2024 | 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 Dec 13, 2024 | |
| Nov 14, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Dec 13, 2024 | |
| Nov 14, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Jan 6, 2025 | |
| Sep 3, 2024 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Sep 20, 2024 | Complaint |
| Nov 3, 2023 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 23, 2023 | Complaint |
| Sep 25, 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 | G · Actual harm Isolated | Corrected Nov 23, 2023 | |
| Sep 25, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0025 | Create arrangements with other facilities to receive patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0281 | Install proper backup exit lighting. | E · Potential harm Pattern | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0324 | Provide properly protected cooking facilities. | E · Potential harm Pattern | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0781 | Have restrictions on the use of portable space heaters.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | 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 Nov 3, 2023 | |
| Sep 25, 2023 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 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 Nov 3, 2023 | |
| Sep 25, 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 Nov 3, 2023 | |
| Sep 25, 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 Nov 3, 2023 | |
| Sep 25, 2023 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | F-0791 | Provide or obtain dental services for each resident.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | 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 Nov 3, 2023 | |
| Sep 25, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0018 | Establish procedures for tracking staff and patients during an emergency.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 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 | C · Minimal Widespread | Corrected Nov 24, 2023 | |
| Sep 25, 2023 | F-0814 | Dispose of garbage and refuse properly.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | C · Minimal Widespread | Corrected Nov 3, 2023 | |
| Sep 25, 2023 | 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 | C · Minimal Widespread | Corrected Nov 3, 2023 | |