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California CDPH state citations and administrative penalties, 1997 to early 2024 (archived dataset). Separate from federal CMS deficiencies.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D44 | E36 | F27 |
| Minimal | A· | B1 |
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 | |
|---|---|---|---|---|---|---|
| Aug 5, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 24, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 10, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| May 27, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 20, 2026 | Fire safety | Fire Safety Standard | 14 | Potential harm | — | Open → |
| Mar 20, 2026 | Health | Health Standard | 16 | Potential harm | — | Open → |
| Sep 5, 2025 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Dec 23, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 2, 2024 | Health | Health Complaint | 9 | Potential harm | — | Open → |
| Sep 13, 2024 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Sep 13, 2024 | Health | Health Standard | 17 | Potential harm | — | Open → |
| May 16, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 4, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 16, 2023 | Fire safety | Fire Safety Standard | 21 | Potential harm | — | Open → |
| Jun 16, 2023 | Health | Health Standard | 20 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Sep 5, 2025 | Denial of payment for new admissions | — | Oct 11, 2025 · 4 days | 555352|Payment Denial|2025-10-11 |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| Oct 5, 2023 violation Oct 28, 2022 | Class AA | Citation Citation AA (HSC 1424) | Patient Care | $80,000 | Death relatedAppealed Open | 040019218 |
| May 19, 2023 violation Nov 2, 2022 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Open | 040018773 |
| Apr 5, 2023 violation Oct 1, 2020 | AP NHPPD | Administrative Penalty |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D44 | E36 | F27 |
| Minimal | A· | B1 | C8 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 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 | D · Potential harm Isolated | Corrected Aug 28, 2026 | Complaint |
| Jul 24, 2026 | 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 Sep 18, 2026 |
“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 |
|---|---|---|---|---|---|
| Llatisha Gonzalez | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 31, 2017 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Llatisha Gonzalez | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 31, 2017 |
| Llatisha Gonzalez | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jul 20, 2017 |
| Llatisha Gonzalez | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jul 20, 2017 |
| Llatisha Gonzalez | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Jul 20, 2017 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Stonehaven Senior Living 1717 S Winery Avenue, Fresno, CA 93727 CCN 555935 | 3.6 km | — | Not rated | Jun 3, 2026 | 18 | — |
| Stonehaven Senior Living 1717 S Winery Ave, Fresno, CA 93727 State license only2 state class AA/A | 3.6 km | 50 lic. | Not CMS rated | — | No inspections in window | — |
| Sierra Vista Healthcare 1715 South Cedar, Fresno, CA 93702 CCN 555866 | 4.3 km | 99 | Jan 9, 2026 | 691 IJ2 harm | $12k | |
| Pacific Gardens Nursing and Rehabilitation Center 577 S. Peach Ave., Fresno, CA 93727 CCN 056207 | 4.7 km | 188 | Apr 24, 2026 | 712 harm1 open | $31k | |
| Evergreen Care Center 5265 East Huntington Avenue, Fresno, CA 93727 CCN 5559203 state class AA/A | 4.9 km | 49 | May 27, 2026 | 552 harm | — | |
| Orchard Post Acute 4840 E.tulare Avenue, Fresno, CA 93727 CCN 0562251 state class AA/A | 5.4 km | 99 | Jun 9, 2026 | 66 | — | |
| California Home for the Aged 6720 E. Kings Canyon, Fresno, CA 93727 CCN 055955 | 6.4 km | 120 | Aug 19, 2025 | 521 harm | — | |
| Burnett Extended Care Center 2715 Fresno St, Fresno, CA 93721 State license only | 7.8 km | 154 lic. | Not CMS rated | — | No inspections in window | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555352 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555352 | 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 |
| California CDPH Licensed Facility Listing CA | 040000061 | state_license, licensed_beds, licensee Linked to the CMS record by exact CCN. | Verified | Oct 16, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| DHPPD: 2 - 11 Days |
| $25,000 |
Open |
| 040018587 |
| Jun 18, 2021 violation Oct 1, 2019 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 1 Day (No Penalty) | $0 | Open | 810016636 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,000 | Open | 040012478 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,050 initial $2,000 | Open | 040012477 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,050 initial $2,000 | Open | 040012476 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,050 initial $2,000 | Open | 040012475 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,000 | Open | 040012473 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,000 | Open | 040012471 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,000 | Open | 040012468 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,000 | Open | 040012466 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $2,000 | Open | 040012464 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012462 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012460 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012459 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012458 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012457 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012456 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012455 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012454 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012453 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012452 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012451 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012450 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012449 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012445 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012444 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012443 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012442 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012441 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012440 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012439 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012438 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012437 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012436 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012434 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012433 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012431 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012430 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012427 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012426 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012425 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012414 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012413 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012412 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012410 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012409 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012408 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012407 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012406 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012405 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012404 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012403 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012402 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012401 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012400 |
| Jul 27, 2016 violation Dec 30, 2015 | Class B | Citation Citation B (HSC 1424) | Financial Occurrence/Fac Not Self Reported | $1,300 initial $2,000 | Closed | 040012397 |
| May 15, 2003 violation Jan 3, 2003 | Class B | Citation Citation A (HSC 1424) | Patient Rights | $2,500 initial $20,000 | Appealed Closed | 040001335 |
| Jun 25, 2002 violation Feb 16, 2002 | Class A | Citation Citation A (HSC 1424) | Patient Rights | $0 initial $20,000 | Appealed Closed | 040001258 |
| Mar 20, 2002 violation Jan 2, 2002 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $1,000 | Closed | 040001244 |
| Feb 26, 2002 violation Sep 21, 2001 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $1,150 initial $1,000 | Appealed Closed | 040001239 |
| Jul 24, 2026 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Sep 18, 2026 | Complaint |
| Jul 10, 2026 | 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 Jul 29, 2026 | Complaint |
| Jul 10, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 29, 2026 | Complaint |
| Jul 10, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 29, 2026 | Complaint |
| May 27, 2026 | 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 Jun 20, 2026 | Complaint |
| May 27, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 20, 2026 | Complaint |
| Mar 20, 2026 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 3, 2026 |
| Mar 20, 2026 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 26, 2026 |
| Mar 20, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 6, 2026 |
| Mar 20, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 29, 2026 |
| Mar 20, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 28, 2026 |
| Mar 20, 2026 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 4, 2026 |
| Mar 20, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 29, 2026 |
| Mar 20, 2026 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 3, 2026 |
| Mar 20, 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 Apr 13, 2026 |
| Mar 20, 2026 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 26, 2026 |
| Mar 20, 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 Mar 27, 2026 |
| Mar 20, 2026 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 6, 2026 |
| Mar 20, 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 16, 2026 |
| Mar 20, 2026 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 2026 | F-0646 | Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 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 16, 2026 |
| Mar 20, 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 16, 2026 |
| Mar 20, 2026 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 2026 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 2026 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 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 16, 2026 |
| Mar 20, 2026 | 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 Apr 16, 2026 |
| Mar 20, 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 | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Mar 20, 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 16, 2026 |
| Mar 20, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 16, 2026 |
| Mar 20, 2026 | F-0911 | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 16, 2026 |
| Mar 20, 2026 | F-0926 | Have policies on smoking. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 16, 2026 |
| Mar 20, 2026 | K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Mar 28, 2026 |
| Mar 20, 2026 | K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 3, 2026 |
| Sep 5, 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 | G · Actual harm Isolated | Corrected Oct 15, 2025 | Complaint |
| Dec 23, 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 23, 2025 | Complaint |
| Oct 2, 2024 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | 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 | D · Potential harm Isolated | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | 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 | F · Potential harm Widespread | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Nov 15, 2024 | Complaint |
| Oct 2, 2024 | F-0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 15, 2024 | Complaint |
| Sep 13, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 10, 2024 |
| Sep 13, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 10, 2024 |
| Sep 13, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 10, 2024 |
| Sep 13, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 10, 2024 |
| Sep 13, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 10, 2024 |
| Sep 13, 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 Oct 10, 2024 |
| Sep 13, 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 Oct 10, 2024 |
| Sep 13, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 10, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 2024 | 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 Oct 15, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 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 | E · Potential harm Pattern | Corrected Oct 15, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 2024 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 15, 2024 |
| Sep 13, 2024 | 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 Oct 15, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 2024 | 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 Oct 15, 2024 |
| Sep 13, 2024 | 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 | F · Potential harm Widespread | Corrected Oct 15, 2024 |
| Sep 13, 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 Oct 15, 2024 |
| Sep 13, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Oct 15, 2024 |
| Sep 13, 2024 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 15, 2024 |
| Sep 13, 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 | F · Potential harm Widespread | Corrected Oct 15, 2024 |
| Sep 13, 2024 | F-0911 | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Environmental Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 15, 2024 |
| May 16, 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 Jun 4, 2024 | Complaint |
| Jan 4, 2024 | F-0573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Jun 16, 2023 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jul 21, 2023 |
| Jun 16, 2023 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jul 21, 2023 |
| Jun 16, 2023 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | E · Potential harm Pattern | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 21, 2023 |
| Jun 16, 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. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0500 | Meet other general requirements that are deficient. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jul 21, 2023 |
| Jun 16, 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 | E · Potential harm Pattern | Corrected Jul 21, 2023 |
| Jun 16, 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 | Corrected Jul 21, 2023 |
| Jun 16, 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 Jul 21, 2023 |
| Jun 16, 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 Jul 21, 2023 |
| Jun 16, 2023 | 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 | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 2023 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 2023 | 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 | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Aug 1, 2023 |
| Jun 16, 2023 | 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 Aug 1, 2023 |
| Jun 16, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 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 Aug 1, 2023 |
| Jun 16, 2023 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 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 Aug 1, 2023 |
| Jun 16, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 2023 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 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 Aug 1, 2023 |
| Jun 16, 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 Aug 1, 2023 |
| Jun 16, 2023 | 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 | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 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 | E · Potential harm Pattern | Corrected Aug 1, 2023 |
| Jun 16, 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 Aug 1, 2023 |
| Jun 16, 2023 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Aug 1, 2023 |
| Jun 16, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Aug 1, 2023 |
| Jun 16, 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 | D · Potential harm Isolated | Corrected Aug 1, 2023 |
| Jun 16, 2023 | E-0007 | Address patient/client population and determine types of services needed. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | E-0020 | Establish policies and procedures including evacuation. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Jul 21, 2023 |
| Jun 16, 2023 | F-0911 | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Environmental Deficiencies · Environment & life safety | B · Minimal Pattern | Corrected Aug 1, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 2.41 (case-mix index 1.43).