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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D27 | E33 | F23 |
| Minimal | A· | B· | C12 |
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 | |
|---|---|---|---|---|---|---|
| Mar 26, 2025 | Fire safety | Fire Safety Standard | 22 | Potential harm | — | Open → |
| Mar 26, 2025 | Health | Health Standard | 13 | Potential harm | — | Open → |
| May 15, 2024 | Fire safety | Fire Safety Standard | 22 | Potential harm | — | Open → |
| May 15, 2024 | Health | Health Standard | 17 | Potential harm | — | Open → |
| Apr 5, 2023 | Health | Health Standard | 11 | Potential harm | — | Open → |
| Apr 12, 2022 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D27 | E33 | F23 |
| Minimal | A· | B· | C12 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Mar 26, 2025 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 30, 2025 | |
| Mar 26, 2025 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Mar 31, 2025 | |
| Mar 26, 2025 | E-0030 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ryder Memorial Hospital Inc | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 13, 1988 |
| Wanda Barreto Martinez | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 1, 2015 |
| Carmen Colon | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Feb 1, 2021 |
| Jose Feliciano | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Feb 1, 2021 |
| Deana Hallman | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | May 18, 2015 |
| Ryder Memorial Hospital Inc | Organization | Trustee | TRUSTEE OF THE SNF | not provided | Jan 13, 1988 |
| Ryder Memorial Hospital Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jan 13, 1988 |
| Wanda Barreto Martinez | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 1, 2015 |
| Carmen Colon | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2021 |
| Jose Feliciano | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2021 |
| Deana Hallman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 18, 2015 |
Coordinates as published by CMS.
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 405018 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 405018 | 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 |
| CMS Provider Information US-CMS | 405018 | county_fips County assigned by locating CMS coordinates in Census county boundaries (the CMS county name did not match the Census code list). | Inferred | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness |
| D · Potential harm Isolated |
| Corrected Apr 2, 2025 |
| Mar 26, 2025 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 6, 2025 |
| Mar 26, 2025 | E-0033 | Establish methods for sharing information. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 8, 2025 |
| Mar 26, 2025 | E-0034 | Provide a means of sharing information on occupancy/needs. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 9, 2025 |
| Mar 26, 2025 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 11, 2025 |
| Mar 26, 2025 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 11, 2025 |
| Mar 26, 2025 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Apr 18, 2025 |
| Mar 26, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 25, 2025 |
| Mar 26, 2025 | 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 | E · Potential harm Pattern | Corrected May 16, 2025 |
| Mar 26, 2025 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 3, 2025 |
| Mar 26, 2025 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 15, 2025 |
| Mar 26, 2025 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 2, 2025 |
| Mar 26, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 25, 2025 |
| Mar 26, 2025 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 20, 2025 |
| Mar 26, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 2, 2025 |
| Mar 26, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 30, 2025 |
| Mar 26, 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 | D · Potential harm Isolated | Corrected Apr 9, 2025 |
| Mar 26, 2025 | K-0907 | Ensure medical gas and vacuum systems have documented maintenance programs. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 6, 2025 |
| Mar 26, 2025 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 30, 2025 |
| Mar 26, 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 | E · Potential harm Pattern | Corrected Jun 6, 2025 |
| Mar 26, 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 May 15, 2025 |
| Mar 26, 2025 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 15, 2025 |
| Mar 26, 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 15, 2025 |
| Mar 26, 2025 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 15, 2025 |
| Mar 26, 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 | E · Potential harm Pattern | Corrected May 15, 2025 |
| Mar 26, 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 | E · Potential harm Pattern | Corrected May 15, 2025 |
| Mar 26, 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 | E · Potential harm Pattern | Corrected May 15, 2025 |
| Mar 26, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 15, 2025 |
| Mar 26, 2025 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected May 15, 2025 |
| Mar 26, 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 May 15, 2025 |
| Mar 26, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected May 15, 2025 |
| Mar 26, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 15, 2025 |
| May 15, 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 | E · Potential harm Pattern | Corrected Mar 20, 2024 |
| May 15, 2024 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 11, 2024 |
| May 15, 2024 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 16, 2024 |
| May 15, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 26, 2024 |
| May 15, 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 | D · Potential harm Isolated | Corrected May 1, 2024 |
| May 15, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 30, 2024 |
| May 15, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| May 15, 2024 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| May 15, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 1, 2024 |
| May 15, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 27, 2024 |
| May 15, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| May 15, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| May 15, 2024 | K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. Electrical Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 11, 2024 |
| May 15, 2024 | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 13, 2024 |
| May 15, 2024 | K-0915 | Have proper power supply for life support equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 19, 2024 |
| May 15, 2024 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 24, 2024 |
| May 15, 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 Jun 7, 2024 |
| May 15, 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 May 24, 2024 |
| May 15, 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 29, 2024 |
| May 15, 2024 | 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 | F · Potential harm Widespread | Corrected May 16, 2024 |
| May 15, 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 May 16, 2024 |
| May 15, 2024 | 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 | F · Potential harm Widespread | Corrected May 29, 2024 |
| May 15, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 27, 2024 |
| May 15, 2024 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 29, 2024 |
| May 15, 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 17, 2024 |
| May 15, 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 | E · Potential harm Pattern | Corrected Jun 3, 2024 |
| May 15, 2024 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 24, 2024 |
| May 15, 2024 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 15, 2024 | 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 Jun 7, 2024 |
| May 15, 2024 | 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 | F · Potential harm Widespread | Corrected Jun 17, 2024 |
| May 15, 2024 | F-0924 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2024 |
| May 15, 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 | F · Potential harm Widespread | Corrected May 20, 2024 |
| May 15, 2024 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Apr 12, 2024 |
| May 15, 2024 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Apr 19, 2024 |
| May 15, 2024 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Apr 12, 2024 |
| May 15, 2024 | E-0023 | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Apr 12, 2024 |
| May 15, 2024 | E-0032 | Provide primary/alternate means for communication. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Mar 20, 2024 |
| May 15, 2024 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Apr 12, 2024 |
| May 15, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 19, 2024 |
| Apr 5, 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 May 30, 2023 |
| Apr 5, 2023 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 10, 2023 |
| Apr 5, 2023 | 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 Apr 10, 2023 |
| Apr 5, 2023 | 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 Apr 11, 2023 |
| Apr 5, 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 | F · Potential harm Widespread | Corrected May 15, 2023 |
| Apr 5, 2023 | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Apr 5, 2023 |
| Apr 5, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 25, 2023 |
| Apr 5, 2023 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 30, 2023 |
| Apr 5, 2023 | 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 | F · Potential harm Widespread | Corrected May 15, 2023 |
| Apr 5, 2023 | F-0924 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 9, 2023 |
| Apr 5, 2023 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 20, 2023 |
| Apr 12, 2022 | 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 | E · Potential harm Pattern | Corrected Apr 25, 2022 |
| Apr 12, 2022 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 25, 2022 |
| Apr 12, 2022 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 25, 2022 |
| Apr 12, 2022 | 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 25, 2022 |
| Apr 12, 2022 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 22, 2022 |
| Apr 12, 2022 | K-0221 | Provide rooms that can be unlocked from inside without a key. Egress Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 25, 2022 |
| Apr 12, 2022 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 25, 2022 |
| Apr 12, 2022 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 25, 2022 |
| Apr 12, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 25, 2022 |
| Apr 12, 2022 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 25, 2022 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 5.01 (case-mix index 1.13).