| Jun 10, 2026 | 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 Jul 16, 2026 | Complaint |
| Dec 10, 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 | Corrected Jan 12, 2026 | Complaint |
| Dec 10, 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 Jan 12, 2026 | Complaint |
| Apr 30, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0022 | Establish policies and procedures for sheltering.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0025 | Create arrangements with other facilities to receive patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0031 | Provide emergency officials' contact information.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | E-0041 | Implement emergency and standby power systems.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | K-0241 | Have correct number of accessible exits for each story. | D · Potential harm Isolated | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | K-0252 | Provide at least two remote exits on each floor or fire section of the building. | D · Potential harm Isolated | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | K-0311 | Have an enclosure around a vertical opening shaft. | F · Potential harm Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | 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 Jun 17, 2025 | |
| Apr 30, 2025 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | 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 Jun 3, 2025 | |
| Apr 30, 2025 | F-0551 | Give the resident's representative the ability to exercise the resident's rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 3, 2025 | |
| Apr 30, 2025 | 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 Jun 3, 2025 | |
| Apr 30, 2025 | 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 Jun 3, 2025 | |
| Apr 30, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 3, 2025 | |
| Apr 30, 2025 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jun 3, 2025 | |
| Apr 30, 2025 | 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 Jun 3, 2025 | |
| Apr 30, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | C · Minimal Widespread | Corrected Jun 17, 2025 | |
| Apr 30, 2025 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Jun 17, 2025 | |
| Apr 23, 2024 | K-0241 | Have correct number of accessible exits for each story. | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Apr 23, 2024 | K-0252 | Provide at least two remote exits on each floor or fire section of the building. | D · Potential harm Isolated | Corrected May 8, 2024 | |
| Apr 23, 2024 | K-0311 | Have an enclosure around a vertical opening shaft. | F · Potential harm Widespread | Corrected May 8, 2024 | |
| Apr 23, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 22, 2024 | |
| Apr 23, 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 May 22, 2024 | |
| Apr 23, 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 May 22, 2024 | |
| Apr 23, 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 May 22, 2024 | |
| Apr 23, 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 May 22, 2024 | |
| Apr 23, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 22, 2024 | |
| Apr 23, 2024 | F-0848 | Provide a neutral and fair arbitration process and agree to arbitrator and venue.Administration Deficiencies · Administration & records | B · Minimal Pattern | Corrected May 22, 2024 | |
| Nov 10, 2022 | F-0675 | Honor each resident's preferences, choices, values and beliefs.Quality of Life and Care Deficiencies · Clinical care | H · Actual harm Pattern | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 | G · Actual harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E · Potential harm Pattern | Corrected Feb 1, 2023 | |
| Nov 10, 2022 | K-0241 | Have correct number of accessible exits for each story. | D · Potential harm Isolated | Corrected Jan 30, 2023 | |
| Nov 10, 2022 | K-0252 | Provide at least two remote exits on each floor or fire section of the building. | D · Potential harm Isolated | Corrected Jan 30, 2023 | |
| Nov 10, 2022 | K-0311 | Have an enclosure around a vertical opening shaft. | F · Potential harm Widespread | Corrected Jan 30, 2023 | |
| Nov 10, 2022 | K-0351 | Install an approved automatic sprinkler system. | D · Potential harm Isolated | Corrected Dec 9, 2022 | |
| Nov 10, 2022 | 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 Feb 1, 2023 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | F-0551 | Give the resident's representative the ability to exercise the resident's rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 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 Feb 21, 2023 | |
| Nov 10, 2022 | F-0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 21, 2023 | |
| Nov 10, 2022 | 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 Feb 21, 2023 | |
| Nov 10, 2022 | 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 23, 2023 | |
| Nov 10, 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 | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 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 | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 21, 2023 | |
| Nov 10, 2022 | 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 Feb 21, 2023 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | 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 Feb 21, 2023 | |
| Nov 10, 2022 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | 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 | E · Potential harm Pattern | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | 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 Feb 21, 2023 | |
| Nov 10, 2022 | 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 Feb 21, 2023 | |
| Nov 10, 2022 | F-0711 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Feb 21, 2023 | |
| Nov 10, 2022 | F-0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Dec 21, 2022 | |
| Nov 10, 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 | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 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 Feb 21, 2023 | |
| Nov 10, 2022 | F-0790 | Provide routine and 24-hour emergency dental care for each resident.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 21, 2023 | |
| Nov 10, 2022 | F-0825 | Provide or get specialized rehabilitative services as required for a resident.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | 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 Feb 21, 2023 | |
| Nov 10, 2022 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |
| Nov 10, 2022 | F-0886 | Perform COVID19 testing on residents and staff.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0888 | Ensure staff are vaccinated for COVID-19Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | F-0946 | Provide training in compliance and ethics.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 21, 2022 | |
| Nov 10, 2022 | 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 Dec 21, 2022 | |