| Mar 27, 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 Apr 30, 2025 | Complaint |
| Mar 27, 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 Apr 30, 2025 | Complaint |
| Mar 27, 2025 | 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 Apr 30, 2025 | Complaint |
| Mar 27, 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 Apr 30, 2025 | Complaint |
| Mar 27, 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 | E · Potential harm Pattern | Corrected Apr 30, 2025 | Complaint |
| Mar 27, 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 Apr 30, 2025 | Complaint |
| Mar 27, 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 Apr 30, 2025 | Complaint |
| Mar 27, 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 | E · Potential harm Pattern | Corrected Apr 30, 2025 | Complaint |
| Mar 27, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 30, 2025 | Complaint |
| Mar 27, 2025 | 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 30, 2025 | Complaint |
| Aug 29, 2024 | E-0001 | Establish an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Oct 3, 2024 | |
| Aug 29, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | D · Potential harm Isolated | Corrected Oct 16, 2024 | |
| Aug 29, 2024 | K-0341 | Install a fire alarm system that can be heard throughout the facility. | D · Potential harm Isolated | Corrected Oct 16, 2024 | |
| Aug 29, 2024 | K-0347 | Properly provide smoke detection systems in areas open to corridors. | D · Potential harm Isolated | Corrected Oct 16, 2024 | |
| Aug 29, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 16, 2024 | |
| Aug 29, 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 | D · Potential harm Isolated | Corrected Oct 16, 2024 | |
| Aug 29, 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 | D · Potential harm Isolated | Corrected Oct 3, 2024 | |
| Aug 29, 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 | D · Potential harm Isolated | Corrected Oct 3, 2024 | Complaint |
| Aug 29, 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 Oct 3, 2024 | |
| Aug 29, 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 Oct 3, 2024 | |
| Aug 29, 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 Oct 3, 2024 | Complaint |
| Aug 29, 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 3, 2024 | |
| Aug 29, 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 | D · Potential harm Isolated | Corrected Oct 3, 2024 | |
| Aug 29, 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 Oct 3, 2024 | |
| Aug 29, 2024 | 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 Oct 3, 2024 | |
| Aug 29, 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 | E · Potential harm Pattern | Corrected Oct 3, 2024 | |
| Aug 29, 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 | E · Potential harm Pattern | Corrected Oct 3, 2024 | |
| Aug 29, 2024 | 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 | F · Potential harm Widespread | Corrected Oct 3, 2024 | |
| May 11, 2021 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0555 | Honor the resident's right to choose his or her attending physician.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | F-0687 | Provide appropriate foot care.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | F-0760 | Ensure that residents are free from significant medication errors.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | 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 Jul 29, 2021 | |
| May 11, 2021 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities.Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | F-0886 | Perform COVID19 testing on residents and staff.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 29, 2021 | |
| May 11, 2021 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 29, 2021 | |
| May 11, 2021 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 29, 2021 | |
| Aug 16, 2019 | K-0161 | Use approved construction type or materials.Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 12, 2020 | |
| Aug 16, 2019 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D · Potential harm Isolated | Corrected Feb 12, 2020 | |
| Aug 16, 2019 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E · Potential harm Pattern | Corrected Feb 12, 2020 | |
| Aug 16, 2019 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D · Potential harm Isolated | Corrected Feb 12, 2020 | |
| Aug 16, 2019 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | D · Potential harm Isolated | Corrected Feb 12, 2020 | |
| Aug 16, 2019 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 12, 2020 | |
| Aug 16, 2019 | 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 Feb 12, 2020 | |
| Aug 16, 2019 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Sep 16, 2019 | |
| Aug 16, 2019 | 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 Sep 16, 2019 | |
| Aug 16, 2019 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Sep 16, 2019 | |