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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L1 |
| Actual harm | G3 | H· | I· |
| Potential harm | D57 | E29 | F52 |
| Minimal | A· | B· | C· |
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 | |
|---|---|---|---|---|---|---|
| Jul 15, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 1, 2026 | Fire safety | Fire Safety Standard | 19 | Potential harm | — | Open → |
| Jun 1, 2026 | Health | Health Standard | 22 | Potential harm | — | Open → |
| Mar 18, 2026 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Sep 4, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 11, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 1, 2025 | Fire safety | Fire Safety Standard | 28 | Potential harm | — | Open → |
| May 1, 2025 | Health | Health Complaint, Health Standard | 21 | Immediate jeopardy | — | Open → |
| Mar 11, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 16, 2024 | Fire safety | Fire Safety Standard | 24 | Potential harm | — | Open → |
| May 16, 2024 | Health | Health Standard | 14 | Potential harm | — | Open → |
| Mar 14, 2024 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Mar 6, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 13, 2023 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 11, 2025 | Civil money penalty (fine) | $74,794 | — | 505098|Fine|43700 |
| May 16, 2024 | Denial of payment for new admissions | — | Aug 16, 2024 · 14 days | 505098|Payment Denial|2024-08-16 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K1 | L1 |
| Actual harm | G3 | H· | I· |
| Potential harm | D57 | E29 | F52 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 15, 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 | D · Potential harm Isolated | Corrected Aug 18, 2026 | Complaint |
| Jul 15, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 18, 2026 | Complaint |
“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 |
|---|---|---|---|---|---|---|
| Avalon Healthcare Bellingham 3121 Squalicum Parkway, Bellingham, WA 98225 CCN 505296 | 2.5 km | 105 | Dec 5, 2025 | 432 harm | $32k | |
| Alderwood Park Health and Rehab of Cascadia 2726 Alderwood Avenue, Bellingham, WA 98225 CCN 505092 | 4 km | 102 | Jan 16, 2026 | 71 | — | |
| Mt Baker Care Center 2905 Connelly Avenue, Bellingham, WA 98225 CCN 505376 | 4.1 km | 70 | May 12, 2026 | 43 | — | |
| Highland Health and Rehabilitation of Cascadia 2400 Samish Way, Bellingham, WA 98229 CCN 505140 | 4.5 km | 44 | Aug 12, 2026 | 734 harm1 open | $64k | |
| North Cascades Health and Rehabilitation 4680 Cordata Parkway, Bellingham, WA 98226 CCN 505393Abuse icon | 7.3 km | 122 | Aug 6, 2026 | 1232 IJ7 harm | $250k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 505098 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 505098 | 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 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Jun 1, 2026 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 9, 2026 |
| Jun 1, 2026 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Aug 12, 2026 |
| Jun 1, 2026 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 12, 2026 |
| Jun 1, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 12, 2026 |
| Jun 1, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 12, 2026 |
| Jun 1, 2026 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 1, 2026 |
| Jun 1, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | 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 | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | 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 | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | 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 Aug 12, 2026 |
| Jun 1, 2026 | 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 Jul 1, 2026 |
| Jun 1, 2026 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 1, 2026 |
| Jun 1, 2026 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 1, 2026 |
| Jun 1, 2026 | 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 Jul 7, 2026 |
| Jun 1, 2026 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 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 | E · Potential harm Pattern | Corrected Jul 7, 2026 |
| Jun 1, 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 | E · Potential harm Pattern | Corrected Jul 7, 2026 |
| Jun 1, 2026 | 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 | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 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 Jul 7, 2026 |
| Jun 1, 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 | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 2026 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 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 | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 2026 | 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 Jul 7, 2026 |
| Jun 1, 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 | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 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 | E · Potential harm Pattern | Corrected Jul 7, 2026 |
| Jun 1, 2026 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jul 7, 2026 |
| Jun 1, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 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 Jul 7, 2026 |
| Jun 1, 2026 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 2026 | 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 Jul 7, 2026 |
| Jun 1, 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 | E · Potential harm Pattern | Corrected Jul 7, 2026 |
| Jun 1, 2026 | 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 Jul 7, 2026 |
| Jun 1, 2026 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 7, 2026 |
| Jun 1, 2026 | 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 | F · Potential harm Widespread | Corrected Jul 7, 2026 |
| Jun 1, 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 | E · Potential harm Pattern | Corrected Jul 7, 2026 |
| Mar 18, 2026 | 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 Apr 17, 2026 | Complaint |
| Mar 18, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Apr 17, 2026 | Complaint |
| Mar 18, 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 | D · Potential harm Isolated | Corrected Apr 17, 2026 | Complaint |
| Mar 18, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 17, 2026 | Complaint |
| Sep 4, 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 Nov 3, 2025 | Complaint |
| Jul 11, 2025 | 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 | D · Potential harm Isolated | Corrected Aug 29, 2025 | Complaint |
| May 1, 2025 | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Administration & records | K · Immediate jeopardy Pattern | Corrected Jun 4, 2025 | Complaint |
| May 1, 2025 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | L · Immediate jeopardy Widespread | Corrected Jun 4, 2025 | Complaint |
| May 1, 2025 | 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 Jun 4, 2025 |
| May 1, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | E-0023 | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | E-0029 | Develop a communication plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 10, 2025 |
| May 1, 2025 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 10, 2025 |
| May 1, 2025 | E-0032 | Provide primary/alternate means for communication. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 10, 2025 |
| May 1, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 29, 2025 |
| May 1, 2025 | 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. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 29, 2025 |
| May 1, 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 Jun 9, 2025 |
| May 1, 2025 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 29, 2025 |
| May 1, 2025 | 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 May 29, 2025 |
| May 1, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 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 May 29, 2025 |
| May 1, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 29, 2025 |
| May 1, 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 | F · Potential harm Widespread | Corrected May 29, 2025 |
| May 1, 2025 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 10, 2025 |
| May 1, 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 May 29, 2025 |
| May 1, 2025 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 9, 2025 |
| May 1, 2025 | 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 Jun 4, 2025 |
| May 1, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| May 1, 2025 | 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 | D · Potential harm Isolated | Corrected Jun 4, 2025 |
| May 1, 2025 | 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 Jun 4, 2025 |
| May 1, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| May 1, 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 Jun 4, 2025 |
| May 1, 2025 | F-0659 | Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 4, 2025 | Complaint |
| May 1, 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 Jun 4, 2025 |
| May 1, 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 Jun 4, 2025 |
| May 1, 2025 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 4, 2025 |
| May 1, 2025 | F-0729 | Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| May 1, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jun 4, 2025 |
| May 1, 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 | D · Potential harm Isolated | Corrected Jun 4, 2025 |
| May 1, 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 | D · Potential harm Isolated | Corrected Jun 4, 2025 |
| May 1, 2025 | 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 Jun 4, 2025 | Complaint |
| May 1, 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 | E · Potential harm Pattern | Corrected Jun 4, 2025 |
| May 1, 2025 | 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 Jun 4, 2025 |
| Mar 11, 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 Apr 20, 2025 | Complaint |
| May 16, 2024 | E-0018 | Establish procedures for tracking staff and patients during an emergency. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 2024 | E-0020 | Establish policies and procedures including evacuation. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 2024 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 2024 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 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. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 15, 2024 |
| May 16, 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 Jun 15, 2024 |
| May 16, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 22, 2024 |
| May 16, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 30, 2024 |
| May 16, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 30, 2024 |
| May 16, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 22, 2024 |
| May 16, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 30, 2024 |
| May 16, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 2024 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 15, 2024 |
| May 16, 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 | F · Potential harm Widespread | Corrected Aug 30, 2024 |
| May 16, 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 Jun 15, 2024 |
| May 16, 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 Jun 15, 2024 |
| May 16, 2024 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 30, 2024 |
| May 16, 2024 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 15, 2024 |
| May 16, 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 | D · Potential harm Isolated | Corrected Jul 22, 2024 |
| May 16, 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 Jul 22, 2024 |
| May 16, 2024 | 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 Jul 22, 2024 |
| May 16, 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 Jul 22, 2024 |
| May 16, 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 Jul 22, 2024 |
| May 16, 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 | E · Potential harm Pattern | Corrected Jul 22, 2024 |
| May 16, 2024 | 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 Jul 22, 2024 |
| May 16, 2024 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jul 22, 2024 |
| May 16, 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 Jul 22, 2024 |
| May 16, 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 Jul 22, 2024 |
| May 16, 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 | D · Potential harm Isolated | Corrected Jul 22, 2024 |
| May 16, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 22, 2024 |
| May 16, 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 | E · Potential harm Pattern | Corrected Jul 22, 2024 |
| Mar 14, 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 | G · Actual harm Isolated | Corrected Apr 17, 2024 | Complaint |
| Mar 14, 2024 | 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 Apr 17, 2024 | Complaint |
| Mar 6, 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 | D · Potential harm Isolated | Corrected Apr 17, 2024 | Complaint |
| Mar 6, 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 Apr 17, 2024 | Complaint |
| Dec 13, 2023 | 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 Jan 13, 2024 | Complaint |
| Dec 13, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 13, 2024 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.73 (case-mix index 1.49).