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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D7 | E12 | F55 |
| Minimal | A· | B· | C19 |
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, 2026 | Fire safety | Fire Safety Standard | 5 | Potential harm | — | Open → |
| Mar 26, 2026 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Sep 25, 2024 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Sep 25, 2024 | Health | Health Standard | 69 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| May 19, 2026 | Civil money penalty (fine) | $41,321 | — | 405034|Fine|139420 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D7 | E12 | F55 |
| Minimal | A· | B· | C19 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Mar 26, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 12, 2026 | |
| Mar 26, 2026 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 12, 2026 | |
| Mar 26, 2026 | K-0353 |
“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 |
|---|---|---|---|---|---|
| Tania Conde Sterling | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Sep 1, 2016 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Tania Conde Sterling | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Sep 1, 2016 |
| Tania Conde Sterling | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2016 |
| Fernando Sepulveda-Irizarry | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Oct 28, 2018 |
| Tania Conde Sterling | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 1, 2016 |
| Tania Conde Sterling | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 1, 2016 |
| Fernando Sepulveda-Irizarry |
Coordinates as published by CMS (geocoding footnote 22).
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Centro De Cuidado Prolongado San Lucas Carr 844 Km 0 5 Cupey, Rio Piedras, PR 00928 CCN 405033 | 2 km | 25 | Mar 27, 2026 | 1164 IJ | — | |
| Alternative Healthcare Solutions LLC Septimo Piso Doctors Center Hospital, San Juan, PR 00910 CCN 405000 | 3.7 km | 22 | May 21, 2026 | 571 open | — | |
| Millennium Institute for Advance Nursing Care Inc Calle Cosme Reparto San Lucas, Rio Piedras, PR 00926 CCN 405030 | 4.1 km | 35 | Mar 11, 2026 | 38 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 405034 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 405034 | 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 | 405034 | 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
| Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected May 12, 2026 |
| Mar 26, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 12, 2026 |
| Mar 26, 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 12, 2026 |
| Mar 26, 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 May 12, 2026 |
| Mar 26, 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 | F · Potential harm Widespread | Corrected May 12, 2026 |
| Mar 26, 2026 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 12, 2026 |
| Mar 26, 2026 | 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 | F · Potential harm Widespread | Corrected May 12, 2026 |
| Mar 26, 2026 | 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 12, 2026 |
| Mar 26, 2026 | 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 12, 2026 |
| Mar 26, 2026 | F-0924 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 12, 2026 |
| Mar 26, 2026 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected May 12, 2026 |
| Sep 25, 2024 | E-0022 | Establish policies and procedures for sheltering. Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 1, 2024 |
| Sep 25, 2024 | E-0023 | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 1, 2024 |
| Sep 25, 2024 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 1, 2024 |
| Sep 25, 2024 | E-0033 | Establish methods for sharing information. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Oct 1, 2024 |
| Sep 25, 2024 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 1, 2024 |
| Sep 25, 2024 | K-0261 | Have properly spaced exits within rooms. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 14, 2024 |
| Sep 25, 2024 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 14, 2024 |
| Sep 25, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 14, 2024 |
| Sep 25, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 14, 2024 |
| Sep 25, 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 Nov 14, 2024 |
| Sep 25, 2024 | K-0751 | Have restrictions on the use of flammable curtains. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 14, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0560 | Protect a residents' right to refuse some types of non-requested transfers within the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0562 | Provide immediate access to any resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0563 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0564 | Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0566 | 1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0567 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0572 | Give residents a notice of rights, rules, services and charges. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0574 | The resident has the right to receive notices in a format and a language he or she understands. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | D · Potential harm Isolated | Corrected Oct 3, 2024 |
| Sep 25, 2024 | F-0579 | Provide information about how to apply for and use Medicare and Medicaid benefits. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 Sep 30, 2024 |
| Sep 25, 2024 | F-0586 | Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0603 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0624 | Prepare residents for a safe transfer or discharge from the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 Sep 25, 2024 |
| Sep 25, 2024 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Nov 20, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 | F · Potential harm Widespread | Corrected Oct 29, 2024 |
| Sep 25, 2024 | F-0800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Nov 4, 2024 |
| Sep 25, 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 Oct 26, 2024 |
| Sep 25, 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 Oct 1, 2024 |
| Sep 25, 2024 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 Nov 20, 2024 |
| Sep 25, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Oct 20, 2024 |
| Sep 25, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 25, 2024 |
| Sep 25, 2024 | 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 | F · Potential harm Widespread | Corrected Sep 30, 2024 |
| Sep 25, 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 Nov 9, 2024 |
| Sep 25, 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 | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Nov 14, 2024 |
| Sep 25, 2024 | F-0696 | Provide appropriate care/assistance for a resident with a prosthesis. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | 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 | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | C · Minimal Widespread | Corrected Oct 29, 2024 |
| Sep 25, 2024 | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Clinical care | C · Minimal Widespread | Corrected Nov 4, 2024 |
| Sep 25, 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 | C · Minimal Widespread | Corrected Oct 1, 2024 |
| Sep 25, 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 | C · Minimal Widespread | Corrected Oct 31, 2024 |
| Sep 25, 2024 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | C · Minimal Widespread | Corrected Oct 1, 2024 |
| Sep 25, 2024 | F-0895 | Have a Compliance and Ethics Program. Administration Deficiencies · Administration & records | C · Minimal Widespread | Corrected Sep 30, 2024 |
| Sep 25, 2024 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Sep 25, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 1.77 (case-mix index 1.24).
| Individual |
| Additional disclosable party |
| ADP OF THE SNF |
| not provided |
| Oct 28, 2018 |