| Dec 18, 2024 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 31, 2025 | |
| Dec 18, 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. | F · Potential harm Widespread | Corrected Jan 31, 2025 | |
| Dec 18, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | D · Potential harm Isolated | Corrected Feb 13, 2025 | |
| Dec 18, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Waiver granted Jan 22, 2025 | |
| Dec 18, 2024 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Jan 31, 2025 | |
| Dec 18, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. | F · Potential harm Widespread | Corrected Jan 31, 2025 | |
| Dec 18, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 6, 2025 | |
| Dec 18, 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 Jan 31, 2025 | |
| Dec 18, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 1, 2025 | |
| Dec 18, 2024 | F-0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 1, 2025 | |
| Dec 18, 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 Feb 1, 2025 | |
| Dec 18, 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 Feb 1, 2025 | |
| Dec 18, 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 Feb 1, 2025 | |
| Dec 18, 2024 | 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 | E · Potential harm Pattern | Corrected Feb 1, 2025 | |
| Dec 18, 2024 | 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 | E · Potential harm Pattern | Corrected Feb 1, 2025 | |
| Dec 18, 2024 | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Feb 1, 2025 | |
| Dec 18, 2024 | F-0838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Feb 1, 2025 | |
| Dec 18, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Feb 1, 2025 | |
| Dec 18, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Feb 1, 2025 | |
| Jun 10, 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 | J · Immediate jeopardy Isolated | Past non-compliance May 30, 2024 | Complaint |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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. | E · Potential harm Pattern | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. | E · Potential harm Pattern | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Electrical Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 2023 | 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 Jun 6, 2023 | |
| Jun 27, 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 Jun 6, 2023 | |
| Jun 27, 2023 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 6, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 2023 | 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 Jul 26, 2023 | |
| Jun 27, 2023 | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 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 Jul 26, 2023 | |
| Jun 27, 2023 | F-0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 26, 2023 | |
| Jun 27, 2023 | 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 Aug 24, 2023 | |
| Dec 2, 2021 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E · Potential harm Pattern | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0293 | Have properly located and lighted "Exit" signs. | F · Potential harm Widespread | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E · Potential harm Pattern | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 12, 2022 | |
| Dec 2, 2021 | 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 Jan 12, 2022 | |
| Dec 2, 2021 | 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 Dec 16, 2021 | |
| Dec 2, 2021 | 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 | E · Potential harm Pattern | Corrected Dec 16, 2021 | |
| Dec 2, 2021 | 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 Dec 16, 2021 | |
| Dec 2, 2021 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 16, 2021 | |