| Jul 24, 2026 | 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 Aug 24, 2026 | Complaint |
| Jun 25, 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 Jul 17, 2026 | Complaint |
| Jun 25, 2026 | 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 17, 2026 | Complaint |
| Jun 25, 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 17, 2026 | Complaint |
| Jun 25, 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 | D · Potential harm Isolated | Corrected Jul 17, 2026 | Complaint |
| Mar 4, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0018 | Establish procedures for tracking staff and patients during an emergency.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0034 | Provide a means of sharing information on occupancy/needs.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0100 | Meet other general requirements.Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D · Potential harm Isolated | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | E · Potential harm Pattern | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D · Potential harm Isolated | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D · Potential harm Isolated | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 2026 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 31, 2026 | |
| Mar 4, 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 Mar 31, 2026 | |
| Mar 4, 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 Mar 31, 2026 | |
| Mar 4, 2026 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 31, 2026 | |
| Mar 4, 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 Apr 23, 2026 | |
| Mar 4, 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 Mar 31, 2026 | |
| Mar 4, 2026 | 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 Apr 23, 2026 | |
| Mar 4, 2026 | F-0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 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 Apr 23, 2026 | |
| Mar 4, 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 | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 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 | E · Potential harm Pattern | Corrected Apr 23, 2026 | Complaint |
| Mar 4, 2026 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 23, 2026 | Complaint |
| Mar 4, 2026 | 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 Apr 23, 2026 | |
| Mar 4, 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 Apr 23, 2026 | |
| Mar 4, 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 | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | 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 23, 2026 | |
| Mar 4, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 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 Apr 23, 2026 | |
| Mar 4, 2026 | 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 Apr 23, 2026 | |
| Mar 4, 2026 | F-0699 | Provide care or services that was trauma informed and/or culturally competent.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 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 23, 2026 | |
| Mar 4, 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 Apr 23, 2026 | |
| Mar 4, 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 | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 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 | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Mar 4, 2026 | 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 Apr 23, 2026 | |
| Mar 4, 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 | D · Potential harm Isolated | Corrected Apr 23, 2026 | |
| Feb 6, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 27, 2026 | Complaint |
| Feb 6, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 27, 2026 | Complaint |
| Feb 6, 2026 | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 27, 2026 | Complaint |
| Feb 6, 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 Feb 27, 2026 | Complaint |
| Nov 24, 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 Dec 12, 2025 | Complaint |
| Nov 17, 2025 | 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 | D · Potential harm Isolated | Corrected Dec 12, 2025 | Complaint |
| Apr 21, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 20, 2025 | Complaint |
| Apr 21, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 20, 2025 | Complaint |
| Mar 14, 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 Apr 3, 2025 | Complaint |
| Mar 14, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 3, 2025 | Complaint |
| Feb 10, 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 Mar 6, 2025 | Complaint |
| Nov 26, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | E-0007 | Address patient/client population and determine types of services needed.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | E-0031 | Provide emergency officials' contact information.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | K-0522 | Have an externally vented heating system. | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | K-0915 | Have proper power supply for life support equipment.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 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 Dec 20, 2024 | |
| Nov 26, 2024 | K-0920 | Ensure proper usage of power strips and extension cords.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 20, 2024 | |
| Nov 26, 2024 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 20, 2024 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 2024 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | 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 | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 2024 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | F-0637 | Assess the resident when there is a significant change in conditionResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 2024 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | 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 Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 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 | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 2024 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 10, 2025 | |
| Nov 26, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 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 | E · Potential harm Pattern | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Nov 26, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 10, 2025 | |
| Nov 26, 2024 | 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 Jan 10, 2025 | |
| Nov 26, 2024 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 | D · Potential harm Isolated | Corrected Jan 10, 2025 | |
| Nov 26, 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 Jan 10, 2025 | |
| Sep 26, 2024 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 14, 2024 | Complaint |
| Jun 5, 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 3, 2024 | Complaint |
| Jun 5, 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 Jul 3, 2024 | Complaint |
| May 28, 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 | D · Potential harm Isolated | Corrected Jul 3, 2024 | Complaint |
| Apr 8, 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 May 22, 2024 | Complaint |
| Apr 8, 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 | D · Potential harm Isolated | Corrected May 22, 2024 | Complaint |
| Nov 30, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 11, 2024 | Complaint |
| Aug 30, 2023 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0018 | Establish procedures for tracking staff and patients during an emergency.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0024 | Establish policies and procedures for volunteers.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0034 | Provide a means of sharing information on occupancy/needs.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0271 | Have exits that are accessible at all times. | E · Potential harm Pattern | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Waiver granted Oct 4, 2023 | |
| Aug 30, 2023 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0363 | Install corridor and hallway doors that block smoke. | E · Potential harm Pattern | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D · Potential harm Isolated | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0523 | Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | D · Potential harm Isolated | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 4, 2023 | |
| Aug 30, 2023 | 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 Oct 4, 2023 | |
| Aug 30, 2023 | 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 | Waiver granted Oct 4, 2023 | |
| Aug 30, 2023 | 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 Oct 4, 2023 | |
| Aug 30, 2023 | 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 Oct 4, 2023 | |
| Aug 30, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | 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 Oct 12, 2023 | |
| Aug 30, 2023 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | 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 | D · Potential harm Isolated | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | 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 12, 2023 | |
| Aug 30, 2023 | 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 Oct 12, 2023 | |
| Aug 30, 2023 | 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 Oct 12, 2023 | |
| Aug 30, 2023 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Oct 12, 2023 | |
| Aug 30, 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 | E · Potential harm Pattern | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | 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 | E · Potential harm Pattern | Corrected Oct 12, 2023 | |
| Aug 30, 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 | E · Potential harm Pattern | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | F-0908 | Keep all essential equipment working safely.Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 12, 2023 | |
| Aug 30, 2023 | 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 Oct 12, 2023 | |