| Mar 23, 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 | G · Actual harm Isolated | Past non-compliance | Complaint |
| Mar 23, 2026 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 9, 2026 | Complaint |
| Mar 23, 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 Apr 9, 2026 | Complaint |
| Feb 17, 2026 | 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 | J · Immediate jeopardy Isolated | Corrected Feb 13, 2026 | Complaint |
| Feb 17, 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 | Past non-compliance | Complaint |
| Nov 18, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 24, 2025 | Complaint |
| Mar 18, 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 Apr 2, 2025 | Complaint |
| Mar 3, 2025 | 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 Apr 1, 2025 | Complaint |
| Feb 21, 2025 | E-0007 | Address patient/client population and determine types of services needed.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | E-0025 | Create arrangements with other facilities to receive patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0271 | Have exits that are accessible at all times. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0311 | Have an enclosure around a vertical opening shaft. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0351 | Install an approved automatic sprinkler system. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 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 31, 2025 | |
| Feb 21, 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 31, 2025 | |
| Feb 21, 2025 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 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 | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 2025 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 2025 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 2025 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 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 Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 2025 | 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 | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0814 | Dispose of garbage and refuse properly.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0848 | Provide a neutral and fair arbitration process and agree to arbitrator and venue.Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 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 Mar 31, 2025 | |
| Feb 21, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 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 | E · Potential harm Pattern | Corrected Mar 31, 2025 | |
| Feb 21, 2025 | 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 Mar 31, 2025 | |
| Feb 21, 2025 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Mar 31, 2025 | |
| Dec 30, 2024 | 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 Jan 27, 2025 | Complaint |
| Dec 30, 2024 | F-0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 27, 2025 | Complaint |
| Nov 13, 2024 | 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 27, 2025 | Complaint |
| Nov 13, 2024 | 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 | E · Potential harm Pattern | Corrected Jan 27, 2025 | Complaint |
| Nov 13, 2024 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 27, 2025 | Complaint |
| Oct 3, 2024 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 18, 2024 | Complaint |
| Oct 3, 2024 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 18, 2024 | Complaint |
| Mar 5, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 30, 2024 | Complaint |
| Mar 5, 2024 | 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 Apr 30, 2024 | Complaint |
| Mar 5, 2024 | 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 Apr 30, 2024 | Complaint |
| Apr 26, 2023 | E-0001 | Establish an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jul 31, 2023 | |
| Apr 26, 2023 | K-0293 | Have properly located and lighted "Exit" signs. | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | K-0324 | Provide properly protected cooking facilities. | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | 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 Aug 7, 2023 | |
| Apr 26, 2023 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | 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 31, 2023 | |
| Apr 26, 2023 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 10, 2023 | |
| Apr 26, 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 | Corrected Jul 31, 2023 | |
| Apr 26, 2023 | 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 Jul 26, 2023 | |
| Apr 26, 2023 | 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 Jun 10, 2023 | |
| Apr 26, 2023 | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 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 | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | 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 Jun 10, 2023 | |
| Apr 26, 2023 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 25, 2023 | |
| Apr 26, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | 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 Jun 10, 2023 | |
| Apr 26, 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 | E · Potential harm Pattern | Corrected Jul 1, 2023 | |
| Apr 26, 2023 | 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 Jul 31, 2023 | |
| Apr 26, 2023 | 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 Jun 10, 2023 | |
| Apr 26, 2023 | 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 Jun 10, 2023 | |
| Apr 26, 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 | E · Potential harm Pattern | Corrected Jul 31, 2023 | |
| Apr 26, 2023 | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jun 10, 2023 | |
| Apr 26, 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 Jun 10, 2023 | |
| Apr 26, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Aug 15, 2023 | |
| Apr 26, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 10, 2023 | |
| Apr 26, 2023 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 14, 2023 | |
| Apr 26, 2023 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jun 10, 2023 | |
| Jan 19, 2021 | E-0001 | Establish an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E · Potential harm Pattern | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 4, 2021 | |
| Jan 19, 2021 | K-0919 | Meet requirements for the use of electrical equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 | D · Potential harm Isolated | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 | E · Potential harm Pattern | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 4, 2021 | |
| Jan 19, 2021 | 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 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | F-0730 | Observe each nurse aide's job performance and give regular training.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |
| Jan 19, 2021 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 4, 2021 | |
| Jan 19, 2021 | 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 4, 2021 | |
| Jan 19, 2021 | 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 Mar 4, 2021 | |