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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D48 | E12 | F36 |
| Minimal | A· | B· | C8 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Aug 20, 2026 | Health | Health Complaint | 5 | Potential harm | 5 | Open → |
| Jul 16, 2026 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Apr 13, 2026 | Health | Health Complaint | 1 | Immediate jeopardy | — | Open → |
| Mar 12, 2026 | Fire safety | Fire Safety Standard | 17 | Potential harm | — | Open → |
| Mar 12, 2026 | Health | Health Standard | 16 | Potential harm | — | Open → |
| Sep 10, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 29, 2025 | Health | Health Complaint | 11 | Immediate jeopardy | — | Open → |
| Jan 29, 2025 | Fire safety | Fire Safety Complaint, Fire Safety Standard | 18 | Potential harm | — | Open → |
| Jan 29, 2025 | Health | Health Complaint, Health Standard | 11 | Potential harm | — | Open → |
| Oct 8, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Nov 29, 2023 | Fire safety | Fire Safety Complaint, Fire Safety Standard | 9 | Potential harm | — | Open → |
| Nov 29, 2023 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Nov 8, 2023 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 12, 2026 | Denial of payment for new admissions | — | May 14, 2026 · 5 days | 245184|Payment Denial|2026-05-14 |
| Mar 12, 2026 | Civil money penalty (fine) | $168,280 | — | 245184|Fine|139381 |
| Jul 29, 2025 | Civil money penalty (fine) | $145,385 | — | 245184|Fine|139373 |
| Nov 8, 2023 | Denial of payment for new admissions | — | Dec 2, 2023 · 33 days | 245184|Payment Denial|2023-12-02 |
| Nov 8, 2023 | Civil money penalty (fine) | $73,544 | — | 245184|Fine|53724 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D48 | E12 | F36 |
| Minimal | A· | B· | C8 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 20, 2026 | 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 | No plan of correction | Complaint |
| Aug 20, 2026 | 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 | No plan of correction |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Nancy Christie | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Paige Coleman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Karen Eaker | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Nina Flannery | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Gregory Hanson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2023 |
| Christopher Schulz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 6, 2026 |
| Jeffrey Treitline | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Brittany Wirth | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Angela Wood | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 18, 2025 |
| Yehuda Zutler | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 5, 2025 |
| 501 Rochester Propco LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Healthcare Services Group Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 5, 2025 |
| Pinnacle Healthcare Solutions LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 5, 2025 |
| Nancy Christie | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Paige Coleman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Karen Eaker | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Nina Flannery | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Gregory Hanson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2023 |
| Alan Markowitz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Christopher Schulz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 6, 2026 |
| Jeffrey Treitline | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Brittany Wirth | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Angela Wood | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
| Yehuda Zutler | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 18, 2025 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Charter House Inc 211 Northwest Second Street, Rochester, MN 55901 CCN 245282 | 1.3 km | 32 | May 19, 2026 | 191 harm | $8,824 | |
| Samaritan Bethany Home on Eighth 24 8th Street Northwest, Rochester, MN 55901 CCN 245530 | 1.7 km | 128 | Mar 26, 2026 | 251 harm | $28k | |
| Edenbrook of Rochester 1875 19th Street Northwest, Rochester, MN 55901 CCN 245409 | 4.2 km | 81 | Jun 15, 2026 | 661 IJ3 harm5 open | $53k | |
| Edenbrook Rochester West 2215 Highway 52 North, Rochester, MN 55901 CCN 245306 | 4.5 km | 48 | May 13, 2026 | 622 IJ1 harm1 open | $161k | |
| Madonna Towers of Rochester 4001 19th Avenue Northwest, Rochester, MN 55901 CCN 245153 | 6.1 km | 62 | Jun 4, 2026 | 311 IJ1 harm | $10k | |
| Rochester Rehabilitation and Living Center 1900 Ballington Boulevard NW, Rochester, MN 55901 CCN 245626 | 7.7 km | 56 | Jun 24, 2026 | 532 IJ3 harm | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 245184 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 245184 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Complaint |
| Aug 20, 2026 | 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 | No plan of correction | Complaint |
| Aug 20, 2026 | 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 | No plan of correction | Complaint |
| Aug 20, 2026 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | No plan of correction | Complaint |
| Jul 16, 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 Aug 31, 2026 | Complaint |
| Jul 16, 2026 | 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 Aug 31, 2026 | Complaint |
| Jul 16, 2026 | 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 Aug 31, 2026 | Complaint |
| Jul 16, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 31, 2026 | Complaint |
| Jul 16, 2026 | 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 Aug 31, 2026 | Complaint |
| Apr 13, 2026 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | J · Immediate jeopardy Isolated | Corrected May 13, 2026 | Complaint |
| Mar 12, 2026 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 13, 2026 |
| Mar 12, 2026 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 2, 2026 |
| Mar 12, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 17, 2026 |
| Mar 12, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 2, 2026 |
| Mar 12, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 17, 2026 |
| Mar 12, 2026 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 3, 2026 |
| Mar 12, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 15, 2026 |
| Mar 12, 2026 | 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 May 15, 2026 |
| Mar 12, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 20, 2026 |
| Mar 12, 2026 | 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 15, 2026 |
| Mar 12, 2026 | 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 May 15, 2026 |
| Mar 12, 2026 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 15, 2026 |
| Mar 12, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 6, 2026 |
| Mar 12, 2026 | 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 May 15, 2026 |
| Mar 12, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 18, 2026 |
| Mar 12, 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 May 18, 2026 |
| Mar 12, 2026 | 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 May 18, 2026 |
| Mar 12, 2026 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 18, 2026 |
| Mar 12, 2026 | 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 18, 2026 |
| Mar 12, 2026 | 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 18, 2026 |
| Mar 12, 2026 | 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 May 18, 2026 |
| Mar 12, 2026 | F-0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 18, 2026 |
| Mar 12, 2026 | 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 May 18, 2026 |
| Mar 12, 2026 | 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 May 18, 2026 |
| Mar 12, 2026 | 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 18, 2026 |
| Mar 12, 2026 | 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 18, 2026 |
| Mar 12, 2026 | 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 May 18, 2026 |
| Mar 12, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 18, 2026 |
| Mar 12, 2026 | 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 May 18, 2026 |
| Mar 12, 2026 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected May 15, 2026 |
| Mar 12, 2026 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 15, 2026 |
| Mar 12, 2026 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected May 15, 2026 |
| Mar 12, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected May 18, 2026 |
| Sep 10, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 30, 2025 | Complaint |
| Sep 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 Sep 30, 2025 | Complaint |
| Jul 29, 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 | J · Immediate jeopardy Isolated | Corrected Aug 20, 2025 | Complaint |
| Jul 29, 2025 | F-0573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 20, 2025 | Complaint |
| Jul 29, 2025 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 20, 2025 | Complaint |
| Jul 29, 2025 | 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 Aug 20, 2025 | Complaint |
| Jul 29, 2025 | 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 20, 2025 | Complaint |
| Jul 29, 2025 | 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 20, 2025 | Complaint |
| Jul 29, 2025 | 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 Aug 20, 2025 | Complaint |
| Jul 29, 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 Aug 20, 2025 | Complaint |
| Jul 29, 2025 | 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 Aug 20, 2025 | Complaint |
| Jul 29, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Aug 20, 2025 | Complaint |
| Jul 29, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Aug 20, 2025 | Complaint |
| Jan 29, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 11, 2025 | Complaint |
| Jan 29, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | 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 12, 2025 |
| Jan 29, 2025 | 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 Mar 12, 2025 |
| Jan 29, 2025 | 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 Mar 12, 2025 |
| Jan 29, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 11, 2025 |
| Jan 29, 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 Mar 11, 2025 |
| Jan 29, 2025 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 11, 2025 |
| Jan 29, 2025 | 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 Mar 11, 2025 |
| Jan 29, 2025 | 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 Mar 11, 2025 |
| Jan 29, 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 Mar 11, 2025 |
| Jan 29, 2025 | 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 Mar 11, 2025 |
| Jan 29, 2025 | 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 Mar 11, 2025 | Complaint |
| Jan 29, 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 | F · Potential harm Widespread | Corrected Mar 11, 2025 |
| Jan 29, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 11, 2025 |
| Jan 29, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 11, 2025 |
| Jan 29, 2025 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Mar 12, 2025 |
| Jan 29, 2025 | 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 | C · Minimal Widespread | Corrected Mar 12, 2025 |
| Oct 8, 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 Nov 4, 2024 | Complaint |
| Oct 8, 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 | Complaint |
| Nov 29, 2023 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 4, 2024 | Complaint |
| Nov 29, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 4, 2024 |
| Nov 29, 2023 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 4, 2024 |
| Nov 29, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 4, 2024 |
| Nov 29, 2023 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 4, 2024 |
| Nov 29, 2023 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Waiver granted |
| Nov 29, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 4, 2024 |
| Nov 29, 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 | Waiver granted |
| Nov 29, 2023 | 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 4, 2024 |
| Nov 29, 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 Jan 4, 2024 |
| Nov 29, 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 Jan 4, 2024 |
| Nov 29, 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 Jan 4, 2024 |
| Nov 29, 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 Jan 4, 2024 |
| Nov 29, 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 Jan 4, 2024 |
| Nov 29, 2023 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jan 4, 2024 |
| Nov 29, 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 Jan 4, 2024 |
| Nov 29, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jan 4, 2024 |
| Nov 8, 2023 | 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 Nov 30, 2023 | Complaint |
| Nov 8, 2023 | 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 Nov 30, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.78 (case-mix index 1.19).