| Jun 12, 2025 | 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 14, 2025 | Complaint |
| Apr 9, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | L · Immediate jeopardy Widespread | Corrected May 15, 2025 | Complaint |
| Apr 9, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected May 15, 2025 | |
| Apr 9, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 2025 | K-0915 | Have proper power supply for life support equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Waiver granted Jan 31, 2026 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 2025 | F-0569 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2025 | |
| Apr 9, 2025 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 15, 2025 | |
| Apr 9, 2025 | 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 May 15, 2025 | |
| Apr 9, 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 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 2025 | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 15, 2025 | |
| Apr 9, 2025 | F-0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected May 15, 2025 | |
| Apr 9, 2025 | F-0714 | Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 2025 | 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 May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 2025 | 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 May 15, 2025 | Complaint |
| Apr 9, 2025 | 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 May 15, 2025 | |
| Apr 9, 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 May 15, 2025 | |
| Apr 9, 2025 | 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 | C · Minimal Widespread | Corrected May 15, 2025 | |
| Apr 9, 2025 | 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 | B · Minimal Pattern | Corrected May 15, 2025 | |
| Apr 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 May 28, 2024 | Complaint |
| May 2, 2022 | 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 May 31, 2022 | |
| May 2, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected May 31, 2022 | |
| May 2, 2022 | K-0511 | Have properly installed electrical wiring and gas equipment. | E · Potential harm Pattern | Corrected May 31, 2022 | |
| May 2, 2022 | F-0570 | Assure the security of all personal funds of residents deposited with the facility.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 31, 2022 | |
| May 2, 2022 | 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 May 31, 2022 | |
| May 2, 2022 | 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 May 31, 2022 | |
| May 2, 2022 | 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 May 31, 2022 | |
| May 2, 2022 | 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 May 31, 2022 | |
| May 2, 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 | D · Potential harm Isolated | Corrected May 31, 2022 | |
| May 2, 2022 | 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 | D · Potential harm Isolated | Corrected May 31, 2022 | |
| May 2, 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 May 31, 2022 | |
| May 2, 2022 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 31, 2022 | |
| May 2, 2022 | F-0885 | Report COVID19 data to residents and families.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 31, 2022 | |
| Jul 3, 2019 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | 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 Aug 28, 2019 | |
| Jul 3, 2019 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0311 | Have an enclosure around a vertical opening shaft. | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 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 Aug 28, 2019 | |
| Jul 3, 2019 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0532 | Have a properly installed and maintained dumbwaiter or escalator. | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 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 | D · Potential harm Isolated | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0912 | Have power receptacles that are properly grounded.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | K-0915 | Have proper power supply for life support equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | 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 Aug 28, 2019 | |
| Jul 3, 2019 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | 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 Aug 28, 2019 | |
| Jul 3, 2019 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | 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 Aug 28, 2019 | |
| Jul 3, 2019 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | 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 Aug 28, 2019 | |
| Jul 3, 2019 | 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 | D · Potential harm Isolated | Corrected Aug 28, 2019 | |
| Jul 3, 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 Aug 28, 2019 | |
| Jul 3, 2019 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 28, 2019 | |
| Jul 3, 2019 | 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 Aug 28, 2019 | |
| Jul 3, 2019 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Aug 28, 2019 | |