| Nov 21, 2025 | K-0351 | Install an approved automatic sprinkler system. | D · Potential harm Isolated | Corrected Jan 30, 2026 | |
| Nov 21, 2025 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 16, 2026 | |
| Nov 21, 2025 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2025 | |
| Nov 21, 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 | D · Potential harm Isolated | Corrected Dec 2, 2025 | |
| Nov 21, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 22, 2025 | |
| Nov 21, 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 | D · Potential harm Isolated | Corrected Dec 2, 2025 | |
| Sep 25, 2024 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | D · Potential harm Isolated | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0311 | Have an enclosure around a vertical opening shaft. | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 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. | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D · Potential harm Isolated | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 14, 2024 | |
| Sep 25, 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 | E · Potential harm Pattern | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 4, 2024 | |
| Sep 25, 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 | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 2024 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 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 4, 2024 | |
| Sep 25, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 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 | D · Potential harm Isolated | Corrected Nov 4, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 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 | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 2024 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 18, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 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 Nov 4, 2024 | |
| Sep 25, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 2024 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 4, 2024 | |
| Sep 25, 2024 | 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 Nov 18, 2024 | |
| Sep 25, 2024 | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 18, 2024 | |
| Sep 25, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | C · Minimal Widespread | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Nov 14, 2024 | |
| Sep 25, 2024 | 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 | C · Minimal Widespread | Corrected Nov 4, 2024 | |
| Jan 9, 2024 | 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 Feb 9, 2024 | Complaint |
| Jan 9, 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 Feb 9, 2024 | Complaint |
| Jul 17, 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 | G · Actual harm Isolated | Corrected Oct 29, 2023 | |
| Jul 17, 2023 | 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 Sep 18, 2023 | |
| Jul 17, 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 Oct 29, 2023 | |
| Jul 17, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F · Potential harm Widespread | Corrected Aug 15, 2023 | |
| Jul 17, 2023 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | F · Potential harm Widespread | Corrected Aug 15, 2023 | |
| Jul 17, 2023 | K-0241 | Have correct number of accessible exits for each story. | F · Potential harm Widespread | Corrected Aug 15, 2023 | |
| Jul 17, 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 | E · Potential harm Pattern | Corrected Aug 18, 2023 | |
| Jul 17, 2023 | 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 Aug 18, 2023 | |
| Jul 17, 2023 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 29, 2023 | |
| Jul 17, 2023 | 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 Dec 17, 2023 | |
| Jul 17, 2023 | 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 Oct 29, 2023 | |
| Jul 17, 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 Oct 29, 2023 | |
| Jul 17, 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 Aug 18, 2023 | |
| Jul 17, 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 Aug 18, 2023 | |
| Jul 17, 2023 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 18, 2023 | |
| Jul 17, 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 | D · Potential harm Isolated | Corrected Oct 29, 2023 | |
| Jul 17, 2023 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 18, 2023 | |
| Jul 17, 2023 | 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 Sep 18, 2023 | |
| Jul 17, 2023 | F-0687 | Provide appropriate foot care.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 18, 2023 | |
| Jul 17, 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 Aug 18, 2023 | |
| Jul 17, 2023 | 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 Aug 18, 2023 | |
| Jul 17, 2023 | 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 Sep 18, 2023 | |
| Jul 17, 2023 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 18, 2023 | |
| Jul 17, 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 | E · Potential harm Pattern | Corrected Aug 18, 2023 | |
| Jul 17, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Aug 18, 2023 | |
| Jul 17, 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 Aug 18, 2023 | |
| Jul 17, 2023 | F-0800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Oct 29, 2023 | |
| Jul 17, 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 Sep 18, 2023 | |
| Jul 17, 2023 | 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 Sep 18, 2023 | |
| Jul 17, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 18, 2023 | |
| Jul 17, 2023 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 29, 2023 | |
| Jul 17, 2023 | F-0917 | Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 29, 2023 | |
| Jul 17, 2023 | 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 Aug 18, 2023 | |
| Jul 17, 2023 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident Rights Deficiencies · Resident rights & abuse/neglect | B · Minimal Pattern | Corrected Aug 18, 2023 | |
| Jul 17, 2023 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | B · Minimal Pattern | Corrected Aug 18, 2023 | |