| Mar 27, 2026 | E-0001 | Establish an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | 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 Apr 27, 2026 | |
| Mar 27, 2026 | K-0311 | Have an enclosure around a vertical opening shaft. | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | K-0351 | Install an approved automatic sprinkler system. | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 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 Apr 27, 2026 | |
| Mar 27, 2026 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | 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 27, 2026 | |
| Mar 27, 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 Apr 27, 2026 | |
| Mar 27, 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 Apr 27, 2026 | |
| Mar 27, 2026 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 27, 2026 | |
| Mar 27, 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 | E · Potential harm Pattern | Corrected May 14, 2026 | |
| Mar 27, 2026 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Mar 27, 2026 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 27, 2026 | |
| Jan 12, 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 | Corrected Jan 29, 2026 | Complaint |
| Jun 14, 2024 | E-0007 | Address patient/client population and determine types of services needed.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0200 | Meet other general requirements. | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0271 | Have exits that are accessible at all times. | E · Potential harm Pattern | Waiver granted Jul 18, 2024 | |
| Jun 14, 2024 | K-0300 | Meet other general requirements that are deficient. | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0324 | Provide properly protected cooking facilities. | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Waiver granted Jul 18, 2024 | |
| Jun 14, 2024 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | 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 | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Jul 18, 2024 | |
| Jun 14, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 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 Jul 18, 2024 | |
| Jun 14, 2024 | 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 Jul 18, 2024 | |
| Jun 14, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 16, 2024 | |
| Jun 14, 2024 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | 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 | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jun 14, 2024 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 18, 2024 | |
| Jan 23, 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 Jan 24, 2024 | Complaint |
| Nov 2, 2023 | 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 | G · Actual harm Isolated | Corrected Nov 20, 2023 | Complaint |
| Nov 2, 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 20, 2023 | Complaint |
| Nov 2, 2023 | F-0741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 20, 2023 | Complaint |
| Sep 23, 2022 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 14, 2022 | |
| Sep 23, 2022 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 12, 2022 | |
| Sep 23, 2022 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 18, 2022 | |
| Sep 23, 2022 | E-0022 | Establish policies and procedures for sheltering.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 14, 2022 | |
| Sep 23, 2022 | E-0025 | Create arrangements with other facilities to receive patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 14, 2022 | |
| Sep 23, 2022 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 14, 2022 | |
| Sep 23, 2022 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Sep 23, 2022 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F · Potential harm Widespread | Corrected Sep 27, 2022 | |
| Sep 23, 2022 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Oct 14, 2022 | |
| Sep 23, 2022 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E · Potential harm Pattern | Corrected Sep 28, 2022 | |
| Sep 23, 2022 | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | F · Potential harm Widespread | Corrected Oct 20, 2022 | |
| Sep 23, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Sep 23, 2022 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Oct 5, 2022 | |
| Sep 23, 2022 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 19, 2022 | |
| Sep 23, 2022 | 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 | E · Potential harm Pattern | Corrected Nov 4, 2022 | |
| Sep 23, 2022 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 30, 2022 | |
| Sep 23, 2022 | 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 Sep 30, 2022 | |
| Sep 23, 2022 | 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 Oct 6, 2022 | |
| Sep 23, 2022 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 11, 2022 | |
| Sep 23, 2022 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 13, 2022 | |
| Sep 23, 2022 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 12, 2022 | |
| Sep 23, 2022 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 24, 2022 | |
| Sep 23, 2022 | 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 Nov 4, 2022 | |
| Sep 23, 2022 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 10, 2022 | |
| Sep 23, 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 Oct 6, 2022 | |
| Sep 23, 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 Oct 28, 2022 | |
| Sep 23, 2022 | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Oct 28, 2022 | |
| Sep 23, 2022 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Oct 14, 2022 | |
| Sep 23, 2022 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Oct 25, 2022 | |
| Sep 23, 2022 | F-0814 | Dispose of garbage and refuse properly.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Oct 24, 2022 | |
| Sep 23, 2022 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 17, 2022 | |
| Sep 23, 2022 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 18, 2022 | |
| Sep 23, 2022 | 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 | D · Potential harm Isolated | Corrected Oct 18, 2022 | |