| Dec 5, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | E-0031 | Provide emergency officials' contact information.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 2, 2026 | |
| Dec 5, 2025 | K-0271 | Have exits that are accessible at all times. | E · Potential harm Pattern | Corrected Jan 6, 2026 | |
| Dec 5, 2025 | K-0281 | Install proper backup exit lighting. | E · Potential harm Pattern | Corrected Jan 6, 2026 | |
| Dec 5, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jan 6, 2026 | |
| Dec 5, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Jan 13, 2026 | |
| Dec 5, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Dec 22, 2025 | |
| Dec 5, 2025 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E · Potential harm Pattern | Corrected Jan 6, 2026 | |
| Dec 5, 2025 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 7, 2026 | |
| Dec 5, 2025 | K-0753 | Have restrictions on the use of highly flammable decorations.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 7, 2026 | |
| Dec 5, 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 Jan 7, 2026 | |
| Dec 5, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 7, 2026 | |
| Dec 5, 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 Jan 7, 2026 | |
| Dec 5, 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 Jan 7, 2026 | |
| Dec 5, 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 Jan 7, 2026 | |
| Dec 5, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 7, 2026 | |
| Dec 5, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jan 7, 2026 | |
| Nov 1, 2024 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | E-0022 | Establish policies and procedures for sheltering.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D · Potential harm Isolated | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | K-0753 | Have restrictions on the use of highly flammable decorations.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 5, 2024 | |
| Nov 1, 2024 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 21, 2024 | |
| Nov 1, 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 Nov 21, 2024 | |
| Nov 1, 2024 | 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 Nov 21, 2024 | |
| Nov 1, 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 Nov 21, 2024 | |
| Nov 1, 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 | E · Potential harm Pattern | Corrected Nov 21, 2024 | |
| Nov 1, 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 | E · Potential harm Pattern | Corrected Nov 21, 2024 | |
| Nov 1, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 21, 2024 | |
| Nov 1, 2024 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 21, 2024 | |
| Jun 26, 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 | D · Potential harm Isolated | Past non-compliance May 13, 2024 | Complaint |
| Dec 15, 2023 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jan 26, 2024 | |
| Dec 15, 2023 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jan 26, 2024 | |
| Dec 15, 2023 | K-0100 | Meet other general requirements.Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 3, 2024 | |
| Dec 15, 2023 | 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. | D · Potential harm Isolated | Corrected Dec 15, 2023 | |
| Dec 15, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | D · Potential harm Isolated | Corrected Dec 31, 2023 | |
| Dec 15, 2023 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | D · Potential harm Isolated | Corrected Jan 26, 2024 | |
| Dec 15, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Jan 26, 2024 | |
| Dec 15, 2023 | K-0753 | Have restrictions on the use of highly flammable decorations.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 26, 2024 | |
| Dec 15, 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 Jan 19, 2024 | |
| Dec 15, 2023 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 31, 2023 | |
| Dec 15, 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 Jan 19, 2024 | |
| Dec 15, 2023 | 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 Jan 19, 2024 | |
| Dec 15, 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 Jan 15, 2024 | |
| Dec 15, 2023 | 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 Jan 19, 2024 | |
| Dec 15, 2023 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 19, 2024 | |
| Dec 15, 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 | D · Potential harm Isolated | Corrected Jan 19, 2024 | |
| Dec 15, 2023 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jan 19, 2024 | |