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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D31 | E9 | F35 |
| Minimal | A· | B· | C7 |
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 | |
|---|---|---|---|---|---|---|
| Jul 22, 2026 | Health | Health Complaint | 22 | Immediate jeopardy | 3 | Open → |
| Apr 6, 2026 | Fire safety | Fire Safety Standard | 1 | Minimal | — | Open → |
| Apr 6, 2026 | Health | Health Complaint, Health Standard | 27 | Immediate jeopardy | — | Open → |
| Feb 3, 2025 | Fire safety | Fire Safety Standard | 0 | No citations | — | Open → |
| Feb 3, 2025 | Health | Health Standard | 21 | Potential harm | — | Open → |
| Oct 23, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Nov 30, 2023 | Fire safety | Fire Safety Standard | 1 | Minimal | — | Open → |
| Nov 30, 2023 | Health | Health Complaint, Health Standard | 13 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J3 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D31 | E9 | F35 |
| Minimal | A· | B· | C7 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 22, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | J · Immediate jeopardy Isolated | Corrected Sep 19, 2026 | Complaint |
“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 reports the legal business name as not available.
Not part of a CMS-reported chain.
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Birchwood Care Home 715 West 31st Street, Minneapolis, MN 55408 CCN 24E166 | 0.9 km | 60 | May 19, 2026 | 681 harm | — | |
| Redeemer Health Care Center 625 West 31st Street, Minneapolis, MN 55408 CCN 245520 | 0.9 km | 119 | Aug 25, 2026 | 424 open | — | |
| The Estates at Chateau LLC 2106 Second Avenue South, Minneapolis, MN 55404 CCN 245222 | 1.4 km | 69 | Sep 3, 2026 | 481 IJ10 open | $36k | |
| Benedictine Health Center of Minneapolis 618 East 17th Street, Minneapolis, MN 55404 CCN 245266 | 2.2 km | 90 | Jul 6, 2026 | 351 IJ1 harm | $85k | |
| Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South, Minneapolis, MN 55409 CCN 245055 | 2.2 km | 277 | Apr 30, 2026 | 1271 IJ | — | |
| Jones Harrison Residence 3700 Cedar Lake Avenue, Minneapolis, MN 55416 CCN 245460 | 2.9 km | 120 | Jul 2, 2026 | 581 harm2 open | — | |
| Andrew Residence 1215 South 9th Street, Minneapolis, MN 55404 CCN 24E116 | 2.9 km | 212 | Aug 26, 2026 | 342 IJ | — | |
| Grand Avenue Rest Home 3956 Grand Avenue S0uth, Minneapolis, MN 55409 CCN 24E150 | 3 km | 20 | Jul 9, 2026 | 571 open | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 24E507 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 24E507 | 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
| Jul 22, 2026 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0572 | Give residents a notice of rights, rules, services and charges. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Plan of correction, not yet verified Sep 19, 2026 | Complaint |
| Jul 22, 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 Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 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 | F · Potential harm Widespread | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 2026 | 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 Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 2026 | 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 Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 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 Sep 19, 2026 | Complaint |
| Jul 22, 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 | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 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 | F · Potential harm Widespread | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 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 | Plan of correction, not yet verified Sep 19, 2026 | Complaint |
| Jul 22, 2026 | 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 Sep 19, 2026 | Complaint |
| Jul 22, 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 Sep 19, 2026 | Complaint |
| Jul 22, 2026 | 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 Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Plan of correction, not yet verified Sep 19, 2026 | Complaint |
| Jul 22, 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 | C · Minimal Widespread | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | C · Minimal Widespread | Corrected Sep 19, 2026 | Complaint |
| Jul 22, 2026 | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | C · Minimal Widespread | Corrected Sep 19, 2026 | Complaint |
| Apr 6, 2026 | 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 | J · Immediate jeopardy Isolated | Corrected Mar 31, 2026 |
| Apr 6, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 29, 2026 |
| Apr 6, 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 29, 2026 |
| Apr 6, 2026 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0680 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | 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 29, 2026 |
| Apr 6, 2026 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 29, 2026 |
| Apr 6, 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 Jun 20, 2026 |
| Apr 6, 2026 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | 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 May 29, 2026 |
| Apr 6, 2026 | 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 May 29, 2026 |
| Apr 6, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 20, 2026 |
| Apr 6, 2026 | 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 | F · Potential harm Widespread | Corrected May 29, 2026 | Complaint |
| Apr 6, 2026 | F-0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Jun 20, 2026 |
| Apr 6, 2026 | F-0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Jun 20, 2026 |
| Apr 6, 2026 | 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 Jun 20, 2026 |
| Apr 6, 2026 | F-0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 20, 2026 |
| Apr 6, 2026 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected May 29, 2026 |
| Apr 6, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected May 29, 2026 |
| Feb 3, 2025 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Feb 3, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 2025 | F-0660 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Feb 3, 2025 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 2025 | 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 4, 2025 |
| Feb 3, 2025 | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Apr 4, 2025 |
| Feb 3, 2025 | 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 | E · Potential harm Pattern | Corrected Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 2025 | 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 Apr 4, 2025 |
| Feb 3, 2025 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 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 Apr 4, 2025 |
| Feb 3, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 4, 2025 |
| Feb 3, 2025 | 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 Apr 4, 2025 |
| Feb 3, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Apr 4, 2025 |
| Oct 23, 2024 | 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 Nov 28, 2024 | Complaint |
| Nov 30, 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 Feb 9, 2024 |
| Nov 30, 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 | E · Potential harm Pattern | Corrected Feb 9, 2024 | Complaint |
| Nov 30, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 9, 2024 |
| Nov 30, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 9, 2024 |
| Nov 30, 2023 | 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 Feb 9, 2024 |
| Nov 30, 2023 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 9, 2024 |
| Nov 30, 2023 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Feb 9, 2024 |
| Nov 30, 2023 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 9, 2024 |
| Nov 30, 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 Feb 9, 2024 |
| Nov 30, 2023 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Feb 9, 2024 |
| Nov 30, 2023 | 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 Feb 9, 2024 |
| Nov 30, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Feb 9, 2024 | Complaint |
| Nov 30, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 9, 2024 |
| Nov 30, 2023 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Feb 9, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 2.90 (case-mix index 1.00).