| Dec 17, 2025 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Jan 5, 2026 | |
| Dec 17, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 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 | E · Potential harm Pattern | Corrected Jan 28, 2026 | |
| Dec 17, 2025 | F-0637 | Assess the resident when there is a significant change in conditionResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 2025 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 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 Jan 28, 2026 | |
| Dec 17, 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 Jan 28, 2026 | |
| Dec 17, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 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 | E · Potential harm Pattern | Corrected Jan 28, 2026 | |
| Dec 17, 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 | E · Potential harm Pattern | Corrected Jan 28, 2026 | |
| Dec 17, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 2025 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jan 28, 2026 | |
| Dec 17, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jan 5, 2026 | |
| Nov 19, 2024 | 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 Nov 29, 2024 | |
| Nov 19, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | E · Potential harm Pattern | Corrected Nov 29, 2024 | |
| Nov 19, 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 | E · Potential harm Pattern | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Past non-compliance Nov 11, 2024 | |
| Nov 19, 2024 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 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 Dec 27, 2024 | |
| Nov 19, 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 Dec 27, 2024 | |
| Nov 19, 2024 | 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 Dec 27, 2024 | |
| Nov 19, 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 Dec 27, 2024 | |
| Nov 19, 2024 | 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 Dec 27, 2024 | |
| Nov 19, 2024 | 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 | E · Potential harm Pattern | Corrected Dec 27, 2024 | |
| Nov 19, 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 Dec 27, 2024 | |
| Nov 19, 2024 | F-0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Dec 27, 2024 | |
| Nov 19, 2024 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Nov 29, 2024 | |
| Jul 30, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 23, 2024 | Complaint |
| Dec 20, 2023 | 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 Jan 9, 2024 | |
| Dec 20, 2023 | 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 Feb 3, 2024 | |
| Dec 20, 2023 | 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 Feb 1, 2024 | |
| Dec 20, 2023 | 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 Jan 8, 2024 | |
| Dec 20, 2023 | 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 Feb 3, 2024 | |
| Dec 20, 2023 | 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 Feb 3, 2024 | |
| Dec 20, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 8, 2024 | |
| Dec 20, 2023 | 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 Feb 3, 2024 | |
| Dec 20, 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 | D · Potential harm Isolated | Corrected Jan 8, 2024 | |
| Dec 20, 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 | D · Potential harm Isolated | Corrected Jan 8, 2024 | |
| Dec 20, 2023 | 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 Feb 3, 2024 | |
| Dec 20, 2023 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jan 8, 2024 | |
| Dec 20, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jan 8, 2024 | |