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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L1 |
| Actual harm | G2 | H· | I· |
| Potential harm | D58 | E36 | F16 |
| Minimal | A· | B1 | C2 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Dec 10, 2025 | Health | Health Complaint | 10 | Actual harm | — | Open → |
| Apr 29, 2025 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Dec 22, 2024 | Fire safety | Fire Safety Standard | 15 | Potential harm | — | Open → |
| Dec 22, 2024 | Health | Health Complaint, Health Standard | 19 | Immediate jeopardy | — | Open → |
| Jul 22, 2024 | Health | Health Complaint | 7 | Actual harm | — | Open → |
| Apr 18, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 21, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 29, 2022 | Fire safety | Fire Safety Standard | 20 | Potential harm | — | Open → |
| Apr 29, 2022 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Jun 24, 2021 | Fire safety | Fire Safety Standard | 14 | Potential harm | — | Open → |
| Jun 24, 2021 | Health | Health Standard | 14 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Dec 22, 2024 | Civil money penalty (fine) | $69,664 | — | 335657|Fine|22365 |
| Jul 22, 2024 | Civil money penalty (fine) | $10,527 | — | 335657|Fine|22317 |
| Jan 8, 2024 | Civil money penalty (fine) | $4,938 | — | 335657|Fine|22078 |
| Jan 2, 2024 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|22060 |
| Dec 11, 2023 | Civil money penalty (fine) | $13,635 | — | 335657|Fine|22002 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L1 |
| Actual harm | G2 | H· | I· |
| Potential harm | D58 | E36 | F16 |
| Minimal | A· | B1 | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Dec 10, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 30, 2026 | Complaint |
| Dec 10, 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 Jan 30, 2026 | Complaint |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Gerald Wood | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Oct 26, 2001 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Gerald Wood | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Oct 26, 2001 |
| Rishi Bajaj | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 14, 2025 |
| Yale Lee | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 8, 2025 |
| Gerald Wood | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 1, 2013 |
| Gerald Wood | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 1, 2013 |
| Rishi Bajaj | Individual |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Sapphire Nursing and Rehab at Goshen 46 Harriman Drive, Goshen, NY 10924 CCN 335684 | 7.7 km | 24 | Aug 19, 2026 | 361 open | — | |
| Glen Arden Inc 214 Harriman Drive, Goshen, NY 10924 CCN 335802 | 7.8 km | 40 | Dec 22, 2025 | 292 harm | $108k | |
| Middletown Park Rehab & Health Care Center 121 Dunning Road, Middletown, NY 10940 CCN 335655 | 8.3 km | 230 | Nov 20, 2025 | 312 open | — | |
| Montgomery Nursing and Rehabilitation Center 2817 Albany Post Road, Montgomery, NY 12549 CCN 335396Abuse icon | 10.8 km | 100 | Jul 28, 2026 | 401 harm4 open | — | |
| Highland Rehabilitation and Nursing Center 120 Highland Avenue, Middletown, NY 10940 CCN 335526 | 11.5 km | 98 | Jul 14, 2026 | 593 open | — | |
| The Valley View Center for Nursing Care and Rehab 2 Glenmere Cove Rd, Goshen, NY 10924 CCN 335238 | 12.8 km | 360 | Feb 3, 2026 | 73 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 335657 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 335657 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| New York DOH Health Facility Information NY | 2544 | state_license, licensed_beds, licensee Linked to the CMS record by exact normalized street address and ZIP (the state roster does not publish the CCN). | Inferred | Oct 23, 2026 | Nov 7, 2026 |
| New York DOH Bed Certifications NY | 2544 | capacity, bed_certifications | Verified | Nov 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Nov 20, 2023 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|21984 |
| Nov 13, 2023 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|21968 |
| Nov 6, 2023 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|21947 |
| Oct 30, 2023 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|21941 |
| Oct 23, 2023 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|21918 |
| Oct 17, 2023 | Civil money penalty (fine) | $4,587 | — | 335657|Fine|21901 |
| Dec 10, 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 Jan 30, 2026 | Complaint |
| Dec 10, 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 | E · Potential harm Pattern | Corrected Mar 8, 2026 | Complaint |
| Dec 10, 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 Jan 30, 2026 | Complaint |
| Dec 10, 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 Mar 8, 2026 | Complaint |
| Dec 10, 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 8, 2026 | Complaint |
| Dec 10, 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 | Past non-compliance Nov 28, 2025 | Complaint |
| Dec 10, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 30, 2026 | Complaint |
| Dec 10, 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 | E · Potential harm Pattern | Corrected Jan 30, 2026 | Complaint |
| Apr 29, 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 May 28, 2025 | Complaint |
| Apr 29, 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 May 28, 2025 | Complaint |
| Apr 29, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 28, 2025 | Complaint |
| Apr 29, 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 | D · Potential harm Isolated | Corrected May 28, 2025 | Complaint |
| Apr 29, 2025 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 28, 2025 | Complaint |
| Apr 29, 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 | D · Potential harm Isolated | Corrected May 28, 2025 | Complaint |
| Dec 22, 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 | L · Immediate jeopardy Widespread | Corrected Jan 24, 2025 | Complaint |
| Dec 22, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 10, 2025 |
| Dec 22, 2024 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jan 15, 2025 |
| Dec 22, 2024 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 28, 2025 |
| Dec 22, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Dec 29, 2024 |
| Dec 22, 2024 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 9, 2025 |
| Dec 22, 2024 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 23, 2025 |
| Dec 22, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 23, 2025 |
| Dec 22, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 28, 2025 |
| Dec 22, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 27, 2025 |
| Dec 22, 2024 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 20, 2024 |
| Dec 22, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 9, 2025 |
| Dec 22, 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 | F · Potential harm Widespread | Corrected Jan 21, 2025 |
| Dec 22, 2024 | K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. Electrical Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 10, 2025 |
| Dec 22, 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 | D · Potential harm Isolated | Corrected Jan 27, 2025 |
| Dec 22, 2024 | 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 Jan 13, 2025 |
| Dec 22, 2024 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 24, 2025 | Complaint |
| Dec 22, 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 Jan 24, 2025 |
| Dec 22, 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 Jan 24, 2025 |
| Dec 22, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 24, 2025 |
| Dec 22, 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 | F · Potential harm Widespread | Corrected Jan 24, 2025 |
| Dec 22, 2024 | 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 | E · Potential harm Pattern | Corrected Jan 24, 2025 |
| Dec 22, 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 Jan 24, 2025 |
| Dec 22, 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 Jan 24, 2025 |
| Dec 22, 2024 | 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 24, 2025 |
| Dec 22, 2024 | F-0710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jan 24, 2025 |
| Dec 22, 2024 | 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 Jan 24, 2025 |
| Dec 22, 2024 | 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 24, 2025 | Complaint |
| Dec 22, 2024 | 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 24, 2025 |
| Dec 22, 2024 | 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 Jan 24, 2025 | Complaint |
| Dec 22, 2024 | 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 Jan 24, 2025 | Complaint |
| Dec 22, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 24, 2025 | Complaint |
| Dec 22, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jan 24, 2025 |
| Dec 22, 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 | F · Potential harm Widespread | Corrected Jan 24, 2025 |
| Jul 22, 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 | G · Actual harm Isolated | Corrected Sep 30, 2024 | Complaint |
| Jul 22, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 | Complaint |
| Jul 22, 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 Sep 30, 2024 | Complaint |
| Jul 22, 2024 | 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 | D · Potential harm Isolated | Corrected Sep 30, 2024 | Complaint |
| Jul 22, 2024 | 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 | D · Potential harm Isolated | Corrected Sep 30, 2024 | Complaint |
| Jul 22, 2024 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Sep 30, 2024 | Complaint |
| Jul 22, 2024 | F-0838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Sep 30, 2024 | Complaint |
| Apr 18, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 24, 2024 | Complaint |
| Apr 18, 2024 | 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 May 24, 2024 | Complaint |
| Dec 21, 2023 | 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 20, 2024 | Complaint |
| Apr 29, 2022 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Jun 25, 2022 |
| Apr 29, 2022 | K-0200 | Meet other general requirements. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Aug 8, 2022 |
| Apr 29, 2022 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0522 | Have an externally vented heating system. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 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 | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 25, 2022 |
| Apr 29, 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 Jun 18, 2022 |
| Apr 29, 2022 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 2022 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 18, 2022 |
| Apr 29, 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 Jun 21, 2022 |
| Apr 29, 2022 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 21, 2022 |
| Apr 29, 2022 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 21, 2022 |
| Apr 29, 2022 | 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 21, 2022 |
| Apr 29, 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 Jun 21, 2022 |
| Apr 29, 2022 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 21, 2022 |
| Apr 29, 2022 | F-0888 | Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 21, 2022 |
| Apr 29, 2022 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jun 18, 2022 |
| Apr 29, 2022 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jun 18, 2022 |
| Apr 29, 2022 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | B · Minimal Pattern | Corrected Jun 21, 2022 |
| Jun 24, 2021 | K-0224 | Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 2021 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 2021 | 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 Aug 10, 2021 |
| Jun 24, 2021 | 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 | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 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 | E · Potential harm Pattern | Corrected Aug 10, 2021 |
| Jun 24, 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 Aug 10, 2021 |
| Jun 24, 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 24, 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 Aug 13, 2021 |
| Jun 24, 2021 | 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 Aug 13, 2021 |
| Jun 24, 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 Aug 13, 2021 |
| Jun 24, 2021 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 13, 2021 |
| Jun 24, 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 | E · Potential harm Pattern | Corrected Aug 13, 2021 |
| Jun 24, 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 | E · Potential harm Pattern | Corrected Aug 13, 2021 |
| Jun 24, 2021 | 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 Aug 13, 2021 |
| Jun 24, 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 Aug 13, 2021 |
| Jun 24, 2021 | 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 Aug 13, 2021 |
| Jun 24, 2021 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 13, 2021 |
| Jun 24, 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 | D · Potential harm Isolated | Corrected Aug 13, 2021 |
| Jun 24, 2021 | F-0836 | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Aug 13, 2021 |
| Jun 24, 2021 | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Aug 13, 2021 |
| Jun 24, 2021 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 13, 2021 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.28 (case-mix index 1.44).
| Additional disclosable party |
| ADP OF THE SNF |
| not provided |
| Jan 14, 2025 |
| Yale Lee | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 14, 2025 |