| Nov 19, 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 10, 2025 | Complaint |
| Sep 10, 2025 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | K · Immediate jeopardy Pattern | Corrected Oct 21, 2025 | |
| Sep 10, 2025 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 21, 2025 | |
| Sep 10, 2025 | 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 Oct 21, 2025 | Complaint |
| Sep 10, 2025 | 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 Oct 21, 2025 | |
| Sep 10, 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 | D · Potential harm Isolated | Corrected Oct 21, 2025 | |
| Sep 10, 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 Oct 21, 2025 | |
| Sep 10, 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 Oct 21, 2025 | |
| Sep 10, 2025 | 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 21, 2025 | |
| Sep 10, 2025 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 21, 2025 | |
| Sep 10, 2025 | K-0363 | Install corridor and hallway doors that block smoke. | C · Minimal Widespread | Corrected Oct 2, 2025 | |
| Sep 10, 2025 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | C · Minimal Widespread | Corrected Oct 2, 2025 | |
| Sep 10, 2025 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | C · Minimal Widespread | Corrected Oct 2, 2025 | |
| Sep 10, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. | C · Minimal Widespread | Corrected Oct 2, 2025 | |
| Sep 10, 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 | C · Minimal Widespread | Corrected Oct 2, 2025 | |
| Jul 11, 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 | J · Immediate jeopardy Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 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 | J · Immediate jeopardy Isolated | Past non-compliance Apr 24, 2024 | Complaint |
| Jul 11, 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. | E · Potential harm Pattern | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0324 | Provide properly protected cooking facilities. | F · Potential harm Widespread | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. | F · Potential harm Widespread | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | F · Potential harm Widespread | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. | E · Potential harm Pattern | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E · Potential harm Pattern | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0712 | Have simulated fire drills held at unexpected times.Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | K-0781 | Have restrictions on the use of portable space heaters.Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 19, 2024 | |
| Jul 11, 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 Aug 19, 2024 | |
| Jul 11, 2024 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed.Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 19, 2024 | |
| Jul 11, 2024 | F-0551 | Give the resident's representative the ability to exercise the resident's rights.Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 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 Aug 13, 2024 | |
| Jul 11, 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 Aug 13, 2024 | |
| Jul 11, 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 | E · Potential harm Pattern | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | 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 Aug 13, 2024 | |
| Jul 11, 2024 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0742 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | 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 | E · Potential harm Pattern | Corrected Aug 13, 2024 | |
| Jul 11, 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 Aug 13, 2024 | |
| Jul 11, 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 Aug 13, 2024 | |
| Jul 11, 2024 | 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 Aug 13, 2024 | |
| Jul 11, 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 | F · Potential harm Widespread | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0814 | Dispose of garbage and refuse properly.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Aug 13, 2024 | |
| Jul 11, 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 | E · Potential harm Pattern | Corrected Aug 13, 2024 | |
| Jul 11, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP).Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Aug 19, 2024 | |
| Mar 8, 2023 | 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. | F · Potential harm Widespread | Corrected Apr 4, 2023 | |
| Mar 8, 2023 | F-0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 27, 2023 | |
| Mar 8, 2023 | 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 Mar 27, 2023 | |
| Mar 8, 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 Mar 27, 2023 | |
| Mar 8, 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 Mar 27, 2023 | |
| Mar 8, 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 | E · Potential harm Pattern | Corrected Mar 27, 2023 | |
| Mar 8, 2023 | 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 Mar 27, 2023 | |
| Mar 8, 2023 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 27, 2023 | |
| Mar 8, 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 Mar 27, 2023 | |
| Mar 8, 2023 | F-0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 27, 2023 | |
| Mar 8, 2023 | 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 Mar 27, 2023 | |
| Mar 8, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | C · Minimal Widespread | Corrected Apr 4, 2023 | |
| Mar 8, 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 | C · Minimal Widespread | Corrected Apr 4, 2023 | |
| Mar 8, 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 | C · Minimal Widespread | Corrected Apr 4, 2023 | |
| Mar 8, 2023 | 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 | B · Minimal Pattern | Corrected Mar 27, 2023 | |