| Jun 5, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 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 5, 2026 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | E-0034 | Provide a means of sharing information on occupancy/needs.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D · Potential harm Isolated | Corrected Jul 1, 2026 | |
| Jun 5, 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. | E · Potential harm Pattern | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Jul 1, 2026 | |
| Jun 5, 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 | D · Potential harm Isolated | Corrected Jul 1, 2026 | |
| Jun 5, 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 5, 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 Jul 20, 2026 | |
| Jun 5, 2026 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 20, 2026 | |
| Jun 5, 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 | E · Potential harm Pattern | Corrected Jul 20, 2026 | Complaint |
| Jun 5, 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 | E · Potential harm Pattern | Corrected Jul 20, 2026 | |
| Jun 5, 2026 | 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 Jul 20, 2026 | |
| Jun 5, 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 Jul 20, 2026 | |
| Jun 5, 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 20, 2026 | |
| Jun 5, 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 | E · Potential harm Pattern | Corrected Jul 20, 2026 | |
| Jun 5, 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 Jul 20, 2026 | |
| Jun 5, 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 Jul 20, 2026 | |
| Jun 5, 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 Jul 20, 2026 | |
| Jun 5, 2026 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jul 20, 2026 | |
| Aug 4, 2025 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Oct 23, 2025 | Complaint |
| Mar 5, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected May 8, 2025 | |
| Mar 5, 2025 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. | D · Potential harm Isolated | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F · Potential harm Widespread | Corrected May 8, 2025 | |
| Mar 5, 2025 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 3, 2025 | |
| Mar 5, 2025 | 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 Apr 3, 2025 | |
| Mar 5, 2025 | 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 Apr 3, 2025 | |
| Mar 5, 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 Apr 3, 2025 | |
| Mar 5, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 21, 2025 | |
| Mar 5, 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 | E · Potential harm Pattern | Corrected Apr 18, 2025 | |
| Mar 5, 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 Apr 18, 2025 | |
| Mar 5, 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 Apr 18, 2025 | |
| Mar 5, 2025 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | 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 Apr 18, 2025 | |
| Mar 5, 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 Apr 18, 2025 | |
| Mar 5, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | 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 Apr 18, 2025 | |
| Mar 5, 2025 | F-0660 | Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2025 | |
| Mar 5, 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 18, 2025 | |
| Mar 5, 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 18, 2025 | |
| Mar 5, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 18, 2025 | Complaint |
| Mar 5, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | 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 Apr 18, 2025 | |
| Mar 5, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 18, 2025 | |
| Mar 5, 2025 | 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 Apr 18, 2025 | |
| Nov 7, 2024 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Dec 5, 2024 | Complaint |
| Dec 12, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0007 | Address patient/client population and determine types of services needed.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0009 | Include a process for Emergency Preparedness collaboration.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0013 | Develop Emergency Preparedness policies and procedures.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0015 | Address subsistence needs for staff and patients.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0018 | Establish procedures for tracking staff and patients during an emergency.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0020 | Establish policies and procedures including evacuation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0022 | Establish policies and procedures for sheltering.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0023 | Establish policies and procedures for medical documentation.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0026 | Establish roles under a Waiver declared by secretary.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0029 | Develop a communication plan.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0030 | List the names and contact information of those in the facility.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0032 | Provide primary/alternate means for communication.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0033 | Establish methods for sharing information.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0034 | Provide a means of sharing information on occupancy/needs.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0035 | Provide family notifications of emergency plan.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0036 | Establish emergency prep training and testing.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | E-0037 | Establish staff and initial training requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | E-0039 | Conduct testing and exercise requirements.Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D · Potential harm Isolated | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | F · Potential harm Widespread | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | F · Potential harm Widespread | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Mar 1, 2024 | |
| Dec 12, 2023 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | D · Potential harm Isolated | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | K-0363 | Install corridor and hallway doors that block smoke. | F · Potential harm Widespread | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | K-0511 | Have properly installed electrical wiring and gas equipment. | F · Potential harm Widespread | Corrected Jan 11, 2024 | |
| Dec 12, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | K-0711 | Provide a written emergency evacuation plan.Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | K-0751 | Have restrictions on the use of flammable curtains.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 14, 2024 | |
| Dec 12, 2023 | K-0753 | Have restrictions on the use of highly flammable decorations.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 11, 2024 | |
| Dec 12, 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 Jan 11, 2024 | |
| Dec 12, 2023 | 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 Jan 11, 2024 | |
| Dec 12, 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 Mar 22, 2024 | |
| Dec 12, 2023 | K-0923 | Have proper medical gas storage and administration areas.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 11, 2024 | |
| Dec 12, 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 Jan 11, 2024 | |
| Dec 12, 2023 | 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 15, 2024 | |
| Dec 12, 2023 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 15, 2024 | Complaint |
| Dec 12, 2023 | 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 15, 2024 | |
| Dec 12, 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 | F · Potential harm Widespread | Corrected Jan 15, 2024 | |
| Dec 12, 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 | F · Potential harm Widespread | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 15, 2024 | |
| Dec 12, 2023 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | F-0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 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 | E · Potential harm Pattern | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 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 Jan 15, 2024 | |
| Dec 12, 2023 | F-0685 | Assist a resident in gaining access to vision and hearing services.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 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 Jan 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 2023 | 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 | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 15, 2024 | |
| Dec 12, 2023 | F-0728 | Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 2023 | 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 15, 2024 | |
| Dec 12, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 2023 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jan 15, 2024 | Complaint |
| Dec 12, 2023 | F-0825 | Provide or get specialized rehabilitative services as required for a resident.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | 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 Jan 15, 2024 | |
| Dec 12, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | F-0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 15, 2024 | |
| Dec 12, 2023 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | B · Minimal Pattern | Corrected Jan 15, 2024 | |
| Oct 4, 2023 | 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 Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 | G · Actual harm Isolated | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0699 | Provide care or services that was trauma informed and/or culturally competent.Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0610 | Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 | E · Potential harm Pattern | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0843 | Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 2023 | 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 Nov 17, 2023 | Complaint |
| Oct 4, 2023 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members.Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Nov 17, 2023 | Complaint |
| Oct 4, 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 | E · Potential harm Pattern | Corrected Nov 17, 2023 | Complaint |