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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J5 | K1 | L3 |
| Actual harm | G1 | H· | I· |
| Potential harm | D103 | E62 | F31 |
| Minimal | A· | B· | C7 |
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 | |
|---|---|---|---|---|---|---|
| Jun 9, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 30, 2026 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Mar 13, 2026 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Mar 13, 2026 | Health | Health Standard | 27 | Potential harm | — | Open → |
| Dec 29, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 5, 2025 | Health | Health Complaint | 2 | Immediate jeopardy | — | Open → |
| Dec 4, 2025 | Health | Health Complaint | 8 | Potential harm | — | Open → |
| Aug 27, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 7, 2025 | Health | Health Complaint | 11 | Immediate jeopardy | — | Open → |
| Jun 11, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 24, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Apr 3, 2025 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Feb 14, 2025 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Feb 14, 2025 | Health | Health Complaint, Health Standard | 35 | Immediate jeopardy | — | Open → |
| Jan 9, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 12, 2024 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Nov 7, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Oct 17, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 11, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Sep 25, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 4, 2024 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Jul 24, 2024 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Jul 2, 2024 | Health | Health Complaint | 7 | Immediate jeopardy | — | Open → |
| Jun 27, 2024 | Fire safety | Fire Safety Complaint | 8 | Potential harm | — | Open → |
| Jun 12, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 10, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 13, 2024 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Mar 13, 2024 | Health | Health Complaint, Health Standard | 29 | Immediate jeopardy | — | Open → |
| Nov 28, 2023 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Oct 19, 2023 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 17, 2026 | Civil money penalty (fine) | $67,830 | — | 395015|Fine|145272 |
| Dec 4, 2025 | Civil money penalty (fine) | $16,575 | — | 395015|Fine|137004 |
| Aug 7, 2025 | Civil money penalty (fine) | $12,441 | — | 395015|Fine|134545 |
| Feb 14, 2025 | Denial of payment for new admissions | — | Mar 26, 2025 · 56 days | 395015|Payment Denial|2025-03-26 |
| Feb 14, 2025 | Civil money penalty (fine) | $51,985 | — | 395015|Fine|14225 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J5 | K1 | L3 |
| Actual harm | G1 | H· | I· |
| Potential harm | D103 | E62 | F31 |
| Minimal | A· | B· | C7 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 9, 2026 | 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 Jul 6, 2026 | Complaint |
| Jun 9, 2026 | 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 Jul 6, 2026 |
“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 reports the legal business name as not available.
Not part of a CMS-reported chain.
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Rochester Residence and Care Center 174 Virginia Avenue, Rochester, PA 15074 CCN 395751SFF | 4.3 km | 119 | Not rated | Jul 30, 2026 | 1664 IJ4 harm4 open | $415k |
| Providence Health & Rehab Center 900 Third Ave, Beaver Falls, PA 15010 CCN 395682SFF CandidateAbuse icon | 4.9 km | 180 | Aug 7, 2026 | 1211 IJ2 harm | $50k | |
| Beaver Valley Rehabilitation and Healthcare Center 257 Georgetown Road, Beaver Falls, PA 15010 CCN 395266 | 10.7 km | 120 | Aug 14, 2026 | 66 | — | |
| Concordia at Villa St Joseph 1030 State Street, Baden, PA 15005 CCN 396026 | 11.2 km | 120 | Jun 19, 2026 | 531 IJ2 harm | $32k | |
| Acadia Nursing and Rehab Center 616 Golf Course Road, Aliquippa, PA 15001 CCN 395109 | 11.5 km | 67 | Jun 9, 2026 | 863 IJ | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 395015 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 395015 | 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 |
| Pennsylvania DOH Nursing Homes PA | 20802 | 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 | Sep 17, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Dec 12, 2024 | Civil money penalty (fine) | $31,034 | — | 395015|Fine|14176 |
| Jun 12, 2024 | Civil money penalty (fine) | $50,264 | — | 395015|Fine|14069 |
| Mar 13, 2024 | Denial of payment for new admissions | — | May 4, 2024 · 23 days | 395015|Payment Denial|2024-05-04 |
| Mar 13, 2024 | Civil money penalty (fine) | $89,540 | — | 395015|Fine|13920 |
| Complaint |
| Jun 9, 2026 | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jul 6, 2026 | Complaint |
| Apr 30, 2026 | 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 | G · Actual harm Isolated | Corrected May 27, 2026 | Complaint |
| Apr 30, 2026 | 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 May 27, 2026 | Complaint |
| Apr 30, 2026 | 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 27, 2026 | Complaint |
| Mar 13, 2026 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 11, 2026 |
| Mar 13, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 11, 2026 |
| Mar 13, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 11, 2026 |
| Mar 13, 2026 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 11, 2026 |
| Mar 13, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 11, 2026 |
| Mar 13, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 11, 2026 |
| Mar 13, 2026 | 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 May 11, 2026 |
| Mar 13, 2026 | K-0912 | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 11, 2026 |
| Mar 13, 2026 | 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 11, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 | E · Potential harm Pattern | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 | E · Potential harm Pattern | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 23, 2026 |
| Mar 13, 2026 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 Apr 23, 2026 |
| Mar 13, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected May 11, 2026 |
| Mar 13, 2026 | F-0575 | Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Apr 23, 2026 |
| Mar 13, 2026 | 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 | C · Minimal Widespread | Corrected Apr 23, 2026 |
| Dec 29, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jan 16, 2026 | Complaint |
| Dec 5, 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 | J · Immediate jeopardy Isolated | Past non-compliance Nov 24, 2025 | Complaint |
| Dec 5, 2025 | 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 Dec 19, 2025 | Complaint |
| Dec 4, 2025 | 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 Dec 12, 2025 | Complaint |
| Dec 4, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 5, 2025 | Complaint |
| Dec 4, 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 | E · Potential harm Pattern | Corrected Dec 12, 2025 | Complaint |
| Dec 4, 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 Dec 12, 2025 | Complaint |
| Dec 4, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 5, 2025 | Complaint |
| Dec 4, 2025 | 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 | F · Potential harm Widespread | Corrected Dec 12, 2025 | Complaint |
| Dec 4, 2025 | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 12, 2025 | Complaint |
| Dec 4, 2025 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Dec 12, 2025 | Complaint |
| Aug 27, 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 | Past non-compliance | Complaint |
| Aug 27, 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 | Past non-compliance | Complaint |
| Aug 7, 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 | J · Immediate jeopardy Isolated | Past non-compliance Jul 26, 2025 | Complaint |
| Aug 7, 2025 | 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 Sep 2, 2025 | Complaint |
| Aug 7, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 2, 2025 | Complaint |
| Aug 7, 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 Sep 2, 2025 | Complaint |
| Aug 7, 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 Sep 2, 2025 | Complaint |
| Aug 7, 2025 | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Sep 2, 2025 | Complaint |
| Aug 7, 2025 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Sep 2, 2025 | Complaint |
| Aug 7, 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 Sep 2, 2025 | Complaint |
| Aug 7, 2025 | 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 2, 2025 | Complaint |
| Aug 7, 2025 | 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 | F · Potential harm Widespread | Corrected Sep 2, 2025 | Complaint |
| Aug 7, 2025 | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Sep 2, 2025 | Complaint |
| Jun 11, 2025 | 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 Jun 20, 2025 | Complaint |
| Apr 24, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 7, 2025 | Complaint |
| Apr 24, 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 | E · Potential harm Pattern | Corrected May 7, 2025 | Complaint |
| Apr 3, 2025 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 18, 2025 | Complaint |
| Apr 3, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 18, 2025 | Complaint |
| Apr 3, 2025 | F-0778 | Help the resident make transportation arrangements to and from radiology services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 18, 2025 | Complaint |
| Apr 3, 2025 | 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 | F · Potential harm Widespread | Corrected Apr 18, 2025 | Complaint |
| Feb 14, 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 | J · Immediate jeopardy Isolated | Corrected Mar 13, 2025 | Complaint |
| Feb 14, 2025 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | J · Immediate jeopardy Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 21, 2025 |
| Feb 14, 2025 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 21, 2025 |
| Feb 14, 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. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 21, 2025 |
| Feb 14, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 21, 2025 |
| Feb 14, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 21, 2025 |
| Feb 14, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 21, 2025 |
| Feb 14, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 21, 2025 |
| Feb 14, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 21, 2025 |
| Feb 14, 2025 | 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 Feb 21, 2025 |
| Feb 14, 2025 | K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 21, 2025 |
| Feb 14, 2025 | 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 Feb 21, 2025 |
| Feb 14, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 21, 2025 |
| Feb 14, 2025 | 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 May 2, 2025 | Complaint |
| Feb 14, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 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 May 21, 2025 |
| Feb 14, 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 | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 | Complaint |
| Feb 14, 2025 | F-0620 | Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2025 | Complaint |
| Feb 14, 2025 | F-0622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 2025 | 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 Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 2025 | F-0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | 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 Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 2025 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 2025 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 2025 | 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 Mar 13, 2025 |
| Feb 14, 2025 | F-0841 | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 2, 2025 |
| Feb 14, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 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 Mar 13, 2025 |
| Feb 14, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Feb 14, 2025 | F-0917 | Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 2, 2025 |
| Feb 14, 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 | D · Potential harm Isolated | Corrected Mar 13, 2025 |
| Jan 9, 2025 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jan 17, 2025 | Complaint |
| Dec 12, 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 | E · Potential harm Pattern | Corrected Dec 27, 2024 | Complaint |
| Dec 12, 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 | F · Potential harm Widespread | Corrected Dec 27, 2024 | Complaint |
| Dec 12, 2024 | F-0660 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 27, 2024 | Complaint |
| Dec 12, 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 Dec 27, 2024 | Complaint |
| Dec 12, 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 Dec 27, 2024 | Complaint |
| Nov 7, 2024 | F-0622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 22, 2024 | Complaint |
| Nov 7, 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 | F · Potential harm Widespread | Corrected Nov 22, 2024 | Complaint |
| Nov 7, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 22, 2024 | Complaint |
| Oct 17, 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 | F · Potential harm Widespread | Corrected Oct 25, 2024 | Complaint |
| Oct 11, 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 Oct 25, 2024 | Complaint |
| Oct 11, 2024 | 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 | D · Potential harm Isolated | Corrected Oct 25, 2024 | Complaint |
| Oct 11, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 25, 2024 | Complaint |
| Sep 25, 2024 | 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 8, 2024 | Complaint |
| Sep 4, 2024 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 20, 2024 | Complaint |
| Sep 4, 2024 | F-0573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 20, 2024 | Complaint |
| Sep 4, 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 Sep 20, 2024 | Complaint |
| Sep 4, 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 | D · Potential harm Isolated | Corrected Sep 20, 2024 | Complaint |
| Jul 24, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 8, 2024 | Complaint |
| Jul 24, 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 Aug 8, 2024 | Complaint |
| Jul 24, 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 Aug 8, 2024 | Complaint |
| Jul 24, 2024 | 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 Aug 8, 2024 | Complaint |
| Jul 24, 2024 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 8, 2024 | Complaint |
| Jul 2, 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 | L · Immediate jeopardy Widespread | Corrected Aug 2, 2024 | Complaint |
| Jul 2, 2024 | 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 | L · Immediate jeopardy Widespread | Corrected Aug 2, 2024 | Complaint |
| Jul 2, 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 Aug 2, 2024 | Complaint |
| Jul 2, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 2, 2024 | Complaint |
| Jul 2, 2024 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 2, 2024 | Complaint |
| Jul 2, 2024 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Aug 2, 2024 | Complaint |
| Jul 2, 2024 | F-0848 | Provide a neutral and fair arbitration process and agree to arbitrator and venue. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 2024 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 2024 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 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. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 20, 2024 | Complaint |
| Jun 27, 2024 | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 2024 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 2024 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Aug 2, 2024 | Complaint |
| Jun 27, 2024 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Aug 2, 2024 | Complaint |
| Jun 12, 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 | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| Apr 10, 2024 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 8, 2024 | Complaint |
| Mar 13, 2024 | 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 May 8, 2024 |
| Mar 13, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected May 8, 2024 |
| Mar 13, 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 | K · Immediate jeopardy Pattern | Corrected May 8, 2024 |
| Mar 13, 2024 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 16, 2024 |
| Mar 13, 2024 | K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 16, 2024 |
| Mar 13, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 16, 2024 |
| Mar 13, 2024 | 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. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 16, 2024 |
| Mar 13, 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. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 16, 2024 |
| Mar 13, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 16, 2024 |
| Mar 13, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 16, 2024 |
| Mar 13, 2024 | 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 Apr 16, 2024 |
| Mar 13, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 16, 2024 |
| Mar 13, 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 | F · Potential harm Widespread | Corrected Apr 16, 2024 |
| Mar 13, 2024 | 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 Apr 16, 2024 |
| Mar 13, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 8, 2024 |
| Mar 13, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 8, 2024 |
| Mar 13, 2024 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 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 May 8, 2024 | Complaint |
| Mar 13, 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 May 27, 2024 |
| Mar 13, 2024 | 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 | E · Potential harm Pattern | Corrected May 8, 2024 |
| Mar 13, 2024 | 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 | D · Potential harm Isolated | Corrected May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 8, 2024 |
| Mar 13, 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 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 8, 2024 |
| Mar 13, 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 May 8, 2024 | Complaint |
| Mar 13, 2024 | 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 8, 2024 |
| Mar 13, 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 | E · Potential harm Pattern | Corrected May 8, 2024 |
| Mar 13, 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 | F · Potential harm Widespread | Corrected May 8, 2024 |
| Mar 13, 2024 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 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 May 8, 2024 |
| Mar 13, 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 | F · Potential harm Widespread | Corrected May 8, 2024 |
| Mar 13, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 8, 2024 | Complaint |
| Mar 13, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Apr 16, 2024 |
| Nov 28, 2023 | 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 Dec 27, 2023 | Complaint |
| Nov 28, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 27, 2023 | Complaint |
| Nov 28, 2023 | F-0680 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 27, 2023 | Complaint |
| Nov 28, 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 | E · Potential harm Pattern | Corrected Dec 27, 2023 | Complaint |
| Nov 28, 2023 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 27, 2023 | Complaint |
| Nov 28, 2023 | 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 Dec 27, 2023 | Complaint |
| Oct 19, 2023 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 15, 2023 | Complaint |
| Oct 19, 2023 | 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 Nov 15, 2023 | Complaint |
| Oct 19, 2023 | 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 Nov 15, 2023 | Complaint |
| Oct 19, 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 | E · Potential harm Pattern | Corrected Nov 15, 2023 | Complaint |
| Oct 19, 2023 | 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 Nov 15, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.74 (case-mix index 1.24).