| Mar 4, 2025 | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | L · Immediate jeopardy Widespread | Corrected Apr 24, 2025 | |
| Mar 4, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | L · Immediate jeopardy Widespread | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | L · Immediate jeopardy Widespread | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 17, 2025 | |
| Mar 4, 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 Apr 17, 2025 | |
| Mar 4, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 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 Apr 17, 2025 | |
| Mar 4, 2025 | 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 | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | 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 Apr 17, 2025 | Complaint |
| Mar 4, 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 | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | 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 | D · Potential harm Isolated | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 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 17, 2025 | Complaint |
| Mar 4, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | 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 17, 2025 | |
| Mar 4, 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 Apr 17, 2025 | |
| Mar 4, 2025 | 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 Apr 17, 2025 | |
| Mar 4, 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 | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 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 | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 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 17, 2025 | |
| Mar 4, 2025 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 17, 2025 | |
| Mar 4, 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 17, 2025 | |
| Mar 4, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 17, 2025 | |
| Mar 4, 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 17, 2025 | |
| Mar 4, 2025 | 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 | F · Potential harm Widespread | Corrected Apr 17, 2025 | |
| Mar 4, 2025 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Apr 17, 2025 | |
| Jun 24, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 26, 2024 | Complaint |
| May 23, 2024 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 28, 2024 | |
| May 23, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jun 28, 2024 | |
| May 23, 2024 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Jun 28, 2024 | |
| May 23, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jun 28, 2024 | |
| May 23, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Jun 28, 2024 | |
| May 23, 2024 | 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 28, 2024 | |
| May 23, 2024 | 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 Jun 28, 2024 | |
| May 23, 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 Jun 28, 2024 | |
| May 23, 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 | D · Potential harm Isolated | Corrected Jun 28, 2024 | |
| May 23, 2024 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 28, 2024 | |
| May 23, 2024 | 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 | D · Potential harm Isolated | Corrected Jun 28, 2024 | Complaint |
| May 23, 2024 | 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 Jun 28, 2024 | |
| May 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 Jun 28, 2024 | |
| May 23, 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 Jun 28, 2024 | |
| May 23, 2024 | 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 Jun 28, 2024 | |
| May 23, 2024 | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 28, 2024 | |
| May 23, 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 Jun 28, 2024 | Complaint |
| May 23, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 28, 2024 | |
| May 23, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 28, 2024 | |
| May 23, 2024 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 28, 2024 | |
| Aug 5, 2022 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | K-0100 | Meet other general requirements.Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 11, 2023 | |
| Aug 5, 2022 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | 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 Sep 16, 2022 | |
| Aug 5, 2022 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 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 Nov 8, 2022 | |
| Aug 5, 2022 | K-0341 | Install a fire alarm system that can be heard throughout the facility. | F · Potential harm Widespread | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Nov 8, 2022 | |
| Aug 5, 2022 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Waiver granted | |
| Aug 5, 2022 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E · Potential harm Pattern | Waiver granted | |
| Aug 5, 2022 | K-0511 | Have properly installed electrical wiring and gas equipment. | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 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 Sep 16, 2022 | |
| Aug 5, 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 | E · Potential harm Pattern | Corrected Nov 8, 2022 | |
| Aug 5, 2022 | 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 Nov 8, 2022 | |
| Aug 5, 2022 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 11, 2023 | |
| Aug 5, 2022 | F-0568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | 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 Nov 8, 2022 | |
| Aug 5, 2022 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | 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 Sep 16, 2022 | |
| Aug 5, 2022 | F-0685 | Assist a resident in gaining access to vision and hearing services.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | 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 Nov 8, 2022 | |
| Aug 5, 2022 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 16, 2022 | |
| Aug 5, 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 Nov 8, 2022 | |
| Aug 5, 2022 | 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 | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Sep 16, 2022 | |
| Aug 5, 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 | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Sep 16, 2022 | |
| Aug 5, 2022 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Sep 16, 2022 | |