| Sep 2, 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 | L · Immediate jeopardy Widespread | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | 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 | L · Immediate jeopardy Widespread | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | K-0271 | Have exits that are accessible at all times. | D · Potential harm Isolated | Corrected Oct 24, 2025 | |
| Sep 2, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Oct 24, 2025 | |
| Sep 2, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F · Potential harm Widespread | Corrected Oct 24, 2025 | |
| Sep 2, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Oct 24, 2025 | |
| Sep 2, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | D · Potential harm Isolated | Corrected Nov 7, 2025 | |
| Sep 2, 2025 | K-0531 | Have elevators that firefighters can control in the event of a fire. | F · Potential harm Widespread | Corrected Dec 18, 2025 | |
| Sep 2, 2025 | 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 | D · Potential harm Isolated | Corrected Nov 21, 2025 | |
| Sep 2, 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 Oct 24, 2025 | |
| Sep 2, 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 Dec 22, 2025 | |
| Sep 2, 2025 | 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 24, 2025 | |
| Sep 2, 2025 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 24, 2025 | |
| Sep 2, 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 Oct 23, 2025 | |
| Sep 2, 2025 | 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 | E · Potential harm Pattern | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | 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 | E · Potential harm Pattern | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | 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 Oct 23, 2025 | |
| Sep 2, 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 Oct 23, 2025 | |
| Sep 2, 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 | D · Potential harm Isolated | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | F-0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 23, 2025 | |
| Sep 2, 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 | D · Potential harm Isolated | Corrected Oct 23, 2025 | |
| Sep 2, 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 Oct 23, 2025 | |
| Sep 2, 2025 | F-0837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 23, 2025 | |
| Sep 2, 2025 | 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 23, 2025 | |
| Sep 2, 2025 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Oct 24, 2025 | |
| Sep 2, 2025 | E-0033 | Establish methods for sharing information.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Oct 24, 2025 | |
| Aug 6, 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 | D · Potential harm Isolated | Corrected Dec 3, 2025 | Complaint |
| Aug 6, 2025 | 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 Dec 3, 2025 | Complaint |
| Aug 6, 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 | D · Potential harm Isolated | Corrected Dec 3, 2025 | Complaint |
| Aug 6, 2025 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 3, 2025 | Complaint |
| Aug 6, 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 Dec 3, 2025 | Complaint |
| Aug 6, 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 Dec 3, 2025 | Complaint |
| Aug 6, 2025 | 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 Dec 3, 2025 | Complaint |
| Jul 30, 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 | Corrected Sep 27, 2024 | Complaint |
| Jul 30, 2024 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 27, 2024 | Complaint |
| Jun 4, 2024 | K-0252 | Provide at least two remote exits on each floor or fire section of the building. | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0293 | Have properly located and lighted "Exit" signs. | D · Potential harm Isolated | Corrected Jul 8, 2024 | |
| Jun 4, 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. | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | D · Potential harm Isolated | Corrected Jun 18, 2024 | |
| Jun 4, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | D · Potential harm Isolated | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Electrical Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | 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 Jul 19, 2024 | |
| Jun 4, 2024 | 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 | D · Potential harm Isolated | Corrected Jul 19, 2024 | |
| Jun 4, 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 Jul 19, 2024 | Complaint |
| Jun 4, 2024 | 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 Jul 19, 2024 | Complaint |
| Jun 4, 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 Jul 19, 2024 | |
| Jun 4, 2024 | 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 Jul 19, 2024 | |
| Jun 4, 2024 | 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 Jul 19, 2024 | |
| Jun 4, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 19, 2024 | |
| Jun 4, 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 Jul 19, 2024 | |
| Jun 4, 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 Jul 19, 2024 | Complaint |
| Jun 4, 2024 | 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 Jul 19, 2024 | Complaint |
| Jun 4, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 19, 2024 | |
| Jun 4, 2024 | 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 | D · Potential harm Isolated | Corrected Jul 19, 2024 | |
| Jun 4, 2024 | 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 Jul 19, 2024 | |
| Jun 4, 2024 | 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 | D · Potential harm Isolated | Corrected Jul 19, 2024 | Complaint |
| Jun 4, 2024 | E-0007 | Address patient/client population and determine types of services needed.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 8, 2024 | |
| Jun 4, 2024 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 8, 2024 | |
| Jun 15, 2021 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | E-0007 | Address patient/client population and determine types of services needed.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | E-0035 | Provide family notifications of emergency plan.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0271 | Have exits that are accessible at all times. | E · Potential harm Pattern | Waiver granted Sep 10, 2021 | |
| Jun 15, 2021 | 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 Aug 10, 2021 | |
| Jun 15, 2021 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | D · Potential harm Isolated | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0371 | Have properly sized and located compartments to protect residents from smoke. | E · Potential harm Pattern | Corrected Sep 14, 2021 | |
| Jun 15, 2021 | K-0531 | Have elevators that firefighters can control in the event of a fire. | D · Potential harm Isolated | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0911 | Meet requirements for the installation and maintenance of electrical systems.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 | |
| Jun 15, 2021 | 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 Sep 8, 2021 | |
| Jun 15, 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 Sep 8, 2021 | |
| Jun 15, 2021 | 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 8, 2021 | |
| Jun 15, 2021 | 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 Sep 8, 2021 | |
| Jun 15, 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 | D · Potential harm Isolated | Corrected Sep 8, 2021 | |
| Jun 15, 2021 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 8, 2021 | |
| Jun 15, 2021 | 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 Sep 8, 2021 | |
| Jun 15, 2021 | K-0917 | Ensure electrical receptacles or cover plates have distinctive color or marking.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Aug 10, 2021 | |