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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D34 | E10 | F71 |
| 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 | |
|---|---|---|---|---|---|---|
| Jun 4, 2026 | Fire safety | Fire Safety Standard | 25 | Potential harm | — | Open → |
| Jun 4, 2026 | Health | Health Standard | 6 | Potential harm | — | Open → |
| Mar 18, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 21, 2025 | Fire safety | Fire Safety Standard | 20 | Potential harm | — | Open → |
| Mar 21, 2025 | Health | Health Standard | 6 | Potential harm | — | Open → |
| Jan 7, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 22, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 26, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 25, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 9, 2024 | Fire safety | Fire Safety Standard | 33 | Potential harm | — | Open → |
| Feb 9, 2024 | Health | Health Standard | 19 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Feb 9, 2024 | Civil money penalty (fine) | $113,505 | — | 505390|Fine|43610 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D34 | E10 | F71 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 4, 2026 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 | |
| Jun 4, 2026 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 | |
| Jun 4, 2026 | E-0020 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Public Hospital District 4 of Grant County | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | May 12, 2022 |
| Barbara Carlson | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 21, 2020 |
| Jean Dillenburg | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2014 |
| Cindi Rang | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Dec 15, 2021 |
| Judy Spencer | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 21, 2020 |
| Stephen Wellein | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2014 |
| Erica Gaertner | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Aug 20, 2020 |
| Theresa Palmer | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Feb 4, 2019 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Columbia Basin Hospital 200 Nat Washington Way, Ephrata, WA 98823 CCN 50A181 | 8.9 km | 12 | Apr 24, 2026 | 67 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 505390 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 505390 | 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
| Establish policies and procedures including evacuation. Emergency Preparedness Deficiencies · Emergency preparedness |
| F · Potential harm Widespread |
| Corrected Jun 26, 2026 |
| Jun 4, 2026 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Jun 4, 2026 | E-0029 | Develop a communication plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Jun 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 Jun 26, 2026 |
| Jun 4, 2026 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Jun 4, 2026 | E-0033 | Establish methods for sharing information. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Jun 4, 2026 | E-0034 | Provide a means of sharing information on occupancy/needs. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Jun 4, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jun 26, 2026 |
| Jun 4, 2026 | K-0100 | Meet other general requirements. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 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. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 3, 2026 |
| Jun 4, 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 3, 2026 |
| Jun 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 Jul 3, 2026 |
| Jun 4, 2026 | 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 Jul 3, 2026 |
| Jun 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 Jul 3, 2026 |
| Jun 4, 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 Jun 26, 2026 |
| Jun 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 Jun 26, 2026 |
| Jun 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 Jun 26, 2026 |
| Jun 4, 2026 | 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 | E · Potential harm Pattern | Corrected Jun 26, 2026 |
| Jun 4, 2026 | 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 Jun 26, 2026 |
| Jun 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 Jun 26, 2026 |
| Mar 18, 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 7, 2026 | Complaint |
| Mar 21, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 11, 2025 |
| Mar 21, 2025 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | E-0025 | Create arrangements with other facilities to receive patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | E-0029 | Develop a communication plan. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 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 14, 2025 |
| Mar 21, 2025 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 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 Apr 14, 2025 |
| Mar 21, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 17, 2025 |
| Mar 21, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 21, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 14, 2025 |
| Mar 21, 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 | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 21, 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 Apr 14, 2025 |
| Mar 21, 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 14, 2025 |
| Mar 21, 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 Apr 14, 2025 |
| Mar 21, 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 Apr 14, 2025 |
| Mar 21, 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 | E · Potential harm Pattern | Corrected Apr 22, 2025 |
| Mar 21, 2025 | 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 Apr 22, 2025 |
| Mar 21, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 22, 2025 |
| Mar 21, 2025 | 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 22, 2025 |
| Mar 21, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 22, 2025 |
| Mar 21, 2025 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 22, 2025 |
| Jan 7, 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 Jan 27, 2025 | Complaint |
| Jan 7, 2025 | 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 Jan 27, 2025 | Complaint |
| Aug 22, 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 Sep 24, 2024 | Complaint |
| Aug 22, 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 Sep 24, 2024 | Complaint |
| Jun 26, 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 23, 2024 | Complaint |
| Apr 25, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 1, 2024 | Complaint |
| Feb 9, 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 | G · Actual harm Isolated | Corrected Mar 25, 2024 |
| Feb 9, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0020 | Establish policies and procedures including evacuation. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0036 | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0100 | Meet other general requirements. Construction Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 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 | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 2, 2024 |
| Feb 9, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 12, 2024 |
| Feb 9, 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 Mar 21, 2024 |
| Feb 9, 2024 | K-0522 | Have an externally vented heating system. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 12, 2024 |
| Feb 9, 2024 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 30, 2024 |
| Feb 9, 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 Mar 12, 2024 |
| Feb 9, 2024 | 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 Mar 12, 2024 |
| Feb 9, 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 Mar 12, 2024 |
| Feb 9, 2024 | 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 12, 2024 |
| Feb 9, 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 Mar 12, 2024 |
| Feb 9, 2024 | F-0569 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 25, 2024 |
| Feb 9, 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 | E · Potential harm Pattern | Corrected Mar 25, 2024 |
| Feb 9, 2024 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 25, 2024 |
| Feb 9, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 25, 2024 |
| Feb 9, 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 Mar 25, 2024 |
| Feb 9, 2024 | F-0637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 25, 2024 |
| Feb 9, 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 Mar 25, 2024 |
| Feb 9, 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 Mar 25, 2024 |
| Feb 9, 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 Mar 25, 2024 |
| Feb 9, 2024 | 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 Mar 25, 2024 |
| Feb 9, 2024 | 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 Mar 25, 2024 |
| Feb 9, 2024 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Mar 25, 2024 |
| Feb 9, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 25, 2024 |
| Feb 9, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 25, 2024 |
| Feb 9, 2024 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 25, 2024 |
| Feb 9, 2024 | 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 | F · Potential harm Widespread | Corrected Mar 25, 2024 |
| Feb 9, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 25, 2024 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.25 (case-mix index 1.39).