| May 12, 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 | J · Immediate jeopardy Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 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 Jun 6, 2025 | Complaint |
| May 12, 2025 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | E-0025 | Create arrangements with other facilities to receive patients.Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0293 | Have properly located and lighted "Exit" signs. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0341 | Install a fire alarm system that can be heard throughout the facility. | E · Potential harm Pattern | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Waiver granted | |
| May 12, 2025 | K-0351 | Install an approved automatic sprinkler system. | E · Potential harm Pattern | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0363 | Install corridor and hallway doors that block smoke. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E · Potential harm Pattern | Corrected Jun 6, 2025 | |
| May 12, 2025 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 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 | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 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 Jun 6, 2025 | |
| May 12, 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 Jun 6, 2025 | |
| May 12, 2025 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 6, 2025 | |
| May 12, 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 Jun 6, 2025 | |
| May 12, 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 | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 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 Jun 6, 2025 | |
| May 12, 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 Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 6, 2025 | |
| May 12, 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 | E · Potential harm Pattern | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | 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 6, 2025 | Complaint |
| May 12, 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 Jun 6, 2025 | |
| May 12, 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 | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 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 Jun 6, 2025 | Complaint |
| May 12, 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 Jun 6, 2025 | |
| May 12, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 6, 2025 | |
| May 12, 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 Jun 6, 2025 | |
| May 12, 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 Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0840 | Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 2025 | 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 | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| May 12, 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 | D · Potential harm Isolated | Corrected Jun 6, 2025 | Complaint |
| Jan 28, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Feb 21, 2025 | Complaint |
| Jan 28, 2025 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Feb 21, 2025 | Complaint |
| Jan 28, 2025 | K-0500 | Meet other general requirements that are deficient. | F · Potential harm Widespread | Waiver granted Feb 21, 2025 | Complaint |
| May 28, 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 7, 2024 | Complaint |
| May 28, 2024 | 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 Jun 7, 2024 | Complaint |
| Aug 4, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0511 | Have properly installed electrical wiring and gas equipment. | E · Potential harm Pattern | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Sep 23, 2022 | |
| Aug 4, 2022 | 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 Sep 23, 2022 | |
| Aug 15, 2019 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | K-0331 | Construct fire resistant interior walls. | E · Potential harm Pattern | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E · Potential harm Pattern | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E · Potential harm Pattern | Corrected Oct 24, 2019 | |
| Aug 15, 2019 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | F-0606 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | 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 | F · Potential harm Widespread | Corrected Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | 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 Oct 10, 2019 | |
| Aug 15, 2019 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Plan of correction, not yet verified Oct 24, 2019 | |