| Oct 21, 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 | Past non-compliance Oct 1, 2025 | Complaint |
| May 20, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0281 | Install proper backup exit lighting. | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0311 | Have an enclosure around a vertical opening shaft. | F · Potential harm Widespread | Corrected Jun 20, 2025 | |
| May 20, 2025 | K-0324 | Provide properly protected cooking facilities. | E · Potential harm Pattern | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0351 | Install an approved automatic sprinkler system. | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | D · Potential harm Isolated | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F · Potential harm Widespread | Corrected Jun 30, 2025 | |
| May 20, 2025 | K-0531 | Have elevators that firefighters can control in the event of a fire. | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 13, 2025 | |
| May 20, 2025 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 30, 2025 | |
| May 20, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 30, 2025 | |
| May 20, 2025 | 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 Jun 30, 2025 | |
| May 20, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 30, 2025 | |
| May 20, 2025 | 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 Jun 30, 2025 | |
| May 20, 2025 | 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 Jun 30, 2025 | |
| May 20, 2025 | 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 30, 2025 | |
| May 20, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 30, 2025 | |
| May 20, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 30, 2025 | |
| Oct 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 | F · Potential harm Widespread | Corrected Nov 9, 2024 | Complaint |
| Oct 2, 2024 | 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 Nov 9, 2024 | Complaint |
| Oct 2, 2024 | F-0687 | Provide appropriate foot care.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 9, 2024 | Complaint |
| Oct 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 Nov 9, 2024 | Complaint |
| Oct 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 Nov 9, 2024 | Complaint |
| Oct 2, 2024 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 9, 2024 | Complaint |
| Oct 2, 2024 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 9, 2024 | Complaint |
| Oct 2, 2024 | F-0924 | Put firmly secured handrails on each side of hallways.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 9, 2024 | Complaint |
| Oct 2, 2024 | 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 | Corrected Nov 9, 2024 | Complaint |
| May 15, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 13, 2024 | Complaint |
| May 15, 2024 | F-0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 13, 2024 | Complaint |
| May 15, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 13, 2024 | Complaint |
| Mar 19, 2024 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 10, 2024 | |
| Mar 19, 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. | D · Potential harm Isolated | Corrected May 10, 2024 | |
| Mar 19, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D · Potential harm Isolated | Corrected May 10, 2024 | |
| Mar 19, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 10, 2024 | |
| Mar 19, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 10, 2024 | |
| Mar 19, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 10, 2024 | |
| Mar 19, 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 May 10, 2024 | |
| Mar 19, 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 Apr 30, 2024 | |
| Mar 19, 2024 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 30, 2024 | |
| Mar 19, 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 Apr 30, 2024 | |
| Mar 19, 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 Apr 30, 2024 | |
| Mar 19, 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 Apr 30, 2024 | |
| Mar 19, 2024 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 30, 2024 | |
| Mar 19, 2024 | 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 Apr 30, 2024 | |
| Mar 19, 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 Apr 30, 2024 | |
| Mar 19, 2024 | 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 Apr 30, 2024 | |
| Mar 19, 2024 | F-0710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Apr 30, 2024 | |
| Mar 19, 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 | D · Potential harm Isolated | Corrected Apr 30, 2024 | |
| Mar 19, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 30, 2024 | |
| Mar 19, 2024 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 30, 2024 | |
| Jan 9, 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 Jan 17, 2024 | Complaint |
| Jan 9, 2024 | 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 Jan 18, 2024 | Complaint |
| Sep 22, 2022 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D · Potential harm Isolated | Corrected Nov 7, 2022 | |
| Sep 22, 2022 | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | F · Potential harm Widespread | Corrected Dec 9, 2022 | |
| Sep 22, 2022 | K-0531 | Have elevators that firefighters can control in the event of a fire. | D · Potential harm Isolated | Corrected Nov 2, 2022 | |
| Sep 22, 2022 | K-0781 | Have restrictions on the use of portable space heaters.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2022 | |
| Sep 22, 2022 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 29, 2022 | |
| Sep 22, 2022 | 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 Oct 29, 2022 | |
| Sep 22, 2022 | 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 Oct 29, 2022 | |
| Sep 22, 2022 | 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 29, 2022 | |
| Sep 22, 2022 | 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 29, 2022 | |
| Sep 22, 2022 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Oct 29, 2022 | |
| Sep 22, 2022 | 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 Oct 29, 2022 | |
| Sep 22, 2022 | 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 Oct 29, 2022 | |
| Sep 22, 2022 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Oct 29, 2022 | |
| Sep 22, 2022 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 29, 2022 | |
| Sep 22, 2022 | 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 | C · Minimal Widespread | Corrected Oct 29, 2022 | |
| Sep 22, 2022 | 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 | C · Minimal Widespread | Corrected Oct 29, 2022 | |