| Oct 17, 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 | K · Immediate jeopardy Pattern | Corrected Dec 5, 2024 | Complaint |
| Oct 17, 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 | G · Actual harm Isolated | Corrected Dec 5, 2024 | Complaint |
| Oct 17, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 2, 2025 | |
| Oct 17, 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. | E · Potential harm Pattern | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | K-0231 | Provide large enough exits. | E · Potential harm Pattern | Corrected Jan 7, 2025 | |
| Oct 17, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | E · Potential harm Pattern | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jan 7, 2025 | |
| Oct 17, 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 7, 2025 | |
| Oct 17, 2024 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. | E · Potential harm Pattern | Corrected Jan 2, 2025 | |
| Oct 17, 2024 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 7, 2025 | |
| Oct 17, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 7, 2025 | |
| Oct 17, 2024 | 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 Jan 7, 2025 | |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 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 | E · Potential harm Pattern | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 | F · Potential harm Widespread | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0742 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 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 | E · Potential harm Pattern | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 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 | D · Potential harm Isolated | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 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 Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 22, 2024 | Complaint |
| Oct 17, 2024 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 22, 2024 | Complaint |
| Jun 17, 2024 | 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 | Corrected Jun 18, 2024 | Complaint |
| Apr 18, 2023 | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | L · Immediate jeopardy Widespread | Corrected May 17, 2023 | |
| Apr 18, 2023 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | L · Immediate jeopardy Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0031 | Provide emergency officials' contact information.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0032 | Provide primary/alternate means for communication.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0034 | Provide a means of sharing information on occupancy/needs.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0035 | Provide family notifications of emergency plan.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected May 16, 2023 | |
| Apr 18, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0363 | Install corridor and hallway doors that block smoke. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 2023 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 2, 2023 | |
| Apr 18, 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 2, 2023 | |
| Apr 18, 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 2, 2023 | |
| Apr 18, 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 May 16, 2023 | |
| Apr 18, 2023 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 16, 2023 | |
| Apr 18, 2023 | F-0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 16, 2023 | |
| Apr 18, 2023 | 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 | E · Potential harm Pattern | Corrected May 16, 2023 | |
| Apr 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 May 16, 2023 | |
| Apr 18, 2023 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 16, 2023 | |
| Apr 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 | D · Potential harm Isolated | Corrected May 16, 2023 | |
| Apr 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 May 16, 2023 | |
| Apr 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 May 16, 2023 | |
| Apr 18, 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 | D · Potential harm Isolated | Corrected May 16, 2023 | |
| Apr 18, 2023 | 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 | F · Potential harm Widespread | Corrected May 16, 2023 | |
| Apr 18, 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 | E · Potential harm Pattern | Corrected May 16, 2023 | |
| Apr 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 May 16, 2023 | |
| Apr 18, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 16, 2023 | |
| Dec 8, 2021 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D · Potential harm Isolated | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0324 | Provide properly protected cooking facilities. | D · Potential harm Isolated | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | D · Potential harm Isolated | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | 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 Mar 15, 2022 | |
| Dec 8, 2021 | 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 Mar 15, 2022 | |
| Dec 8, 2021 | 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 Mar 15, 2022 | |
| Dec 8, 2021 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 15, 2022 | |
| Dec 8, 2021 | 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 Dec 13, 2021 | |
| Dec 8, 2021 | 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 Dec 13, 2021 | |
| Dec 8, 2021 | 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 Dec 13, 2021 | |
| Dec 8, 2021 | 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 Dec 13, 2021 | |
| Dec 8, 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 13, 2021 | |