Pinnacle Care of Battle Creek

• F0678 — Quality of Life and Care Deficiencies

  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Mar 27, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178917:ccn:235536

  View official CMS source

• F0680 — Quality of Life and Care Deficiencies

  Ensure the activities program is directed by a qualified professional.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Mar 27, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178920:ccn:235536

  View official CMS source

• F0726 — Nursing and Physician Services Deficiencies

  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.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (May 15, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178918:ccn:235536

  View official CMS source

• F0801 — Nutrition and Dietary Deficiencies

  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.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (May 15, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178915:ccn:235536

  View official CMS source

• F0865 — Administration Deficiencies

  Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (May 15, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178916:ccn:235536

  View official CMS source

• F0947 — Nursing and Physician Services Deficiencies

  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (May 15, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178919:ccn:235536

  View official CMS source

No health-deficiency rows were deterministically linked to this inspection.

• F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Feb 20, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178921:ccn:235536

  View official CMS source

• F0627 — Resident Rights Deficiencies

  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Feb 20, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178922:ccn:235536

  View official CMS source

• F0628 — Resident Rights Deficiencies

  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Feb 20, 2026)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178923:ccn:235536

  View official CMS source

• F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Oct 4, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178924:ccn:235536

  View official CMS source

No health-deficiency rows were deterministically linked to this inspection.

• F0550 — Resident Rights Deficiencies

  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178937:ccn:235536

  View official CMS source

• F0552 — Resident Rights Deficiencies

  Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178938:ccn:235536

  View official CMS source

• F0558 — Resident Rights Deficiencies

  Reasonably accommodate the needs and preferences of each resident.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178930:ccn:235536

  View official CMS source

• F0578 — Resident Rights Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178939:ccn:235536

  View official CMS source

• F0584 — Resident Rights Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178940:ccn:235536

  View official CMS source

• F0605 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178941:ccn:235536

  View official CMS source

• F0628 — Resident Rights Deficiencies

  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178942:ccn:235536

  View official CMS source

• F0636 — Resident Assessment and Care Planning Deficiencies

  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178943:ccn:235536

  View official CMS source

• F0637 — Resident Assessment and Care Planning Deficiencies

  Assess the resident when there is a significant change in condition

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178944:ccn:235536

  View official CMS source

• F0641 — Resident Assessment and Care Planning Deficiencies

  Ensure each resident receives an accurate assessment.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178945:ccn:235536

  View official CMS source

• F0656 — Resident Assessment and Care Planning Deficiencies

  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178946:ccn:235536

  View official CMS source

• F0657 — Resident Assessment and Care Planning Deficiencies

  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178947:ccn:235536

  View official CMS source

• F0679 — Quality of Life and Care Deficiencies

  Provide activities to meet all resident's needs.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178948:ccn:235536

  View official CMS source

• F0684 — Quality of Life and Care Deficiencies

  Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178931:ccn:235536

  View official CMS source

• F0686 — Quality of Life and Care Deficiencies

  Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178926:ccn:235536

  View official CMS source

• F0689 — Quality of Life and Care Deficiencies

  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178925:ccn:235536

  View official CMS source

• F0692 — Quality of Life and Care Deficiencies

  Provide enough food/fluids to maintain a resident's health.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178949:ccn:235536

  View official CMS source

• F0725 — Nursing and Physician Services Deficiencies

  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178932:ccn:235536

  View official CMS source

• F0732 — Nursing and Physician Services Deficiencies

  Post nurse staffing information every day.

  CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178953:ccn:235536

  View official CMS source

• F0756 — Pharmacy Service Deficiencies

  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178933:ccn:235536

  View official CMS source

• F0759 — Pharmacy Service Deficiencies

  Ensure medication error rates are not 5 percent or greater.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178950:ccn:235536

  View official CMS source

• F0761 — Pharmacy Service Deficiencies

  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.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178934:ccn:235536

  View official CMS source

• F0809 — Nutrition and Dietary Deficiencies

  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.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178935:ccn:235536

  View official CMS source

• F0812 — Nutrition and Dietary Deficiencies

  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178927:ccn:235536

  View official CMS source

• F0865 — Administration Deficiencies

  Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178928:ccn:235536

  View official CMS source

• F0880 — Infection Control Deficiencies

  Provide and implement an infection prevention and control program.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178951:ccn:235536

  View official CMS source

• F0883 — Infection Control Deficiencies

  Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Aug 15, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178952:ccn:235536

  View official CMS source

• F0887 — Infection Control Deficiencies

  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178954:ccn:235536

  View official CMS source

• F0919 — Environmental Deficiencies

  Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178936:ccn:235536

  View official CMS source

• F0921 — Environmental Deficiencies

  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 20, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178929:ccn:235536

  View official CMS source

• F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (May 12, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178955:ccn:235536

  View official CMS source

• F0677 — Quality of Life and Care Deficiencies

  Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 17, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178956:ccn:235536

  View official CMS source

• F0690 — Quality of Life and Care Deficiencies

  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (May 12, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178957:ccn:235536

  View official CMS source

• F0925 — Environmental Deficiencies

  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2025)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178958:ccn:235536

  View official CMS source

• F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Oct 28, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178959:ccn:235536

  View official CMS source

• F0684 — Quality of Life and Care Deficiencies

  Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Oct 28, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178960:ccn:235536

  View official CMS source

No health-deficiency rows were deterministically linked to this inspection.

No health-deficiency rows were deterministically linked to this inspection.

• F0550 — Resident Rights Deficiencies

  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178975:ccn:235536

  View official CMS source

• F0561 — Resident Rights Deficiencies

  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178976:ccn:235536

  View official CMS source

• F0565 — Resident Rights Deficiencies

  Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178967:ccn:235536

  View official CMS source

• F0622 — Resident Rights Deficiencies

  Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178978:ccn:235536

  View official CMS source

• F0623 — Resident Rights Deficiencies

  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178979:ccn:235536

  View official CMS source

• F0637 — Resident Assessment and Care Planning Deficiencies

  Assess the resident when there is a significant change in condition

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178981:ccn:235536

  View official CMS source

• F0641 — Resident Assessment and Care Planning Deficiencies

  Ensure each resident receives an accurate assessment.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178968:ccn:235536

  View official CMS source

• F0657 — Resident Assessment and Care Planning Deficiencies

  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178983:ccn:235536

  View official CMS source

• F0660 — Resident Assessment and Care Planning Deficiencies

  Plan the resident's discharge to meet the resident's goals and needs.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178984:ccn:235536

  View official CMS source

• F0677 — Quality of Life and Care Deficiencies

  Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178985:ccn:235536

  View official CMS source

• F0684 — Quality of Life and Care Deficiencies

  Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178986:ccn:235536

  View official CMS source

• F0688 — Quality of Life and Care Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178987:ccn:235536

  View official CMS source

• F0689 — Quality of Life and Care Deficiencies

  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178969:ccn:235536

  View official CMS source

• F0690 — Quality of Life and Care Deficiencies

  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178961:ccn:235536

  View official CMS source

• F0725 — Nursing and Physician Services Deficiencies

  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178970:ccn:235536

  View official CMS source

• F0740 — Quality of Life and Care Deficiencies

  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178988:ccn:235536

  View official CMS source

• F0756 — Pharmacy Service Deficiencies

  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178971:ccn:235536

  View official CMS source

• F0757 — Pharmacy Service Deficiencies

  Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178989:ccn:235536

  View official CMS source

• F0758 — Pharmacy Service Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178990:ccn:235536

  View official CMS source

• F0761 — Pharmacy Service Deficiencies

  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.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178972:ccn:235536

  View official CMS source

• F0812 — Nutrition and Dietary Deficiencies

  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178962:ccn:235536

  View official CMS source

• F0881 — Infection Control Deficiencies

  Implement a program that monitors antibiotic use.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178965:ccn:235536

  View official CMS source

• F0883 — Infection Control Deficiencies

  Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178991:ccn:235536

  View official CMS source

• F0887 — Infection Control Deficiencies

  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Apr 22, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178992:ccn:235536

  View official CMS source

• F0919 — Environmental Deficiencies

  Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jun 6, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178973:ccn:235536

  View official CMS source

• F0558 — Resident Rights Deficiencies

  Reasonably accommodate the needs and preferences of each resident.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Mar 4, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178993:ccn:235536

  View official CMS source

• F0610 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Respond appropriately to all alleged violations.

  CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

  Correction status: Deficient, Provider has date of correction (Mar 4, 2024)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178994:ccn:235536

  View official CMS source

No health-deficiency rows were deterministically linked to this inspection.

No health-deficiency rows were deterministically linked to this inspection.

• F0550 — Resident Rights Deficiencies

  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179010:ccn:235536

  View official CMS source

• F0559 — Resident Rights Deficiencies

  Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179011:ccn:235536

  View official CMS source

• F0565 — Resident Rights Deficiencies

  Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179012:ccn:235536

  View official CMS source

• F0577 — Resident Rights Deficiencies

  Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179025:ccn:235536

  View official CMS source

• F0578 — Resident Rights Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179013:ccn:235536

  View official CMS source

• F0600 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179014:ccn:235536

  View official CMS source

• F0609 — Freedom from Abuse, Neglect, and Exploitation Deficiencies

  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179015:ccn:235536

  View official CMS source

• F0641 — Resident Assessment and Care Planning Deficiencies

  Ensure each resident receives an accurate assessment.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179016:ccn:235536

  View official CMS source

• F0656 — Resident Assessment and Care Planning Deficiencies

  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178996:ccn:235536

  View official CMS source

• F0657 — Resident Assessment and Care Planning Deficiencies

  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178997:ccn:235536

  View official CMS source

• F0677 — Quality of Life and Care Deficiencies

  Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178998:ccn:235536

  View official CMS source

• F0679 — Quality of Life and Care Deficiencies

  Provide activities to meet all resident's needs.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178999:ccn:235536

  View official CMS source

• F0684 — Quality of Life and Care Deficiencies

  Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179000:ccn:235536

  View official CMS source

• F0686 — Quality of Life and Care Deficiencies

  Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179017:ccn:235536

  View official CMS source

• F0698 — Quality of Life and Care Deficiencies

  Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179018:ccn:235536

  View official CMS source

• F0725 — Nursing and Physician Services Deficiencies

  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179001:ccn:235536

  View official CMS source

• F0726 — Nursing and Physician Services Deficiencies

  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.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179002:ccn:235536

  View official CMS source

• F0727 — Nursing and Physician Services Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179019:ccn:235536

  View official CMS source

• F0730 — Nursing and Physician Services Deficiencies

  Observe each nurse aide's job performance and give regular training.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179020:ccn:235536

  View official CMS source

• F0744 — Quality of Life and Care Deficiencies

  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179003:ccn:235536

  View official CMS source

• F0756 — Pharmacy Service Deficiencies

  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179004:ccn:235536

  View official CMS source

• F0759 — Pharmacy Service Deficiencies

  Ensure medication error rates are not 5 percent or greater.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179021:ccn:235536

  View official CMS source

• F0761 — Pharmacy Service Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179022:ccn:235536

  View official CMS source

• F0812 — Nutrition and Dietary Deficiencies

  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:178995:ccn:235536

  View official CMS source

• F0839 — Administration Deficiencies

  Employ staff that are licensed, certified, or registered in accordance with state laws.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179023:ccn:235536

  View official CMS source

• F0849 — Administration Deficiencies

  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.

  CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179024:ccn:235536

  View official CMS source

• F0880 — Infection Control Deficiencies

  Provide and implement an infection prevention and control program.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179005:ccn:235536

  View official CMS source

• F0883 — Infection Control Deficiencies

  Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179006:ccn:235536

  View official CMS source

• F0887 — Infection Control Deficiencies

  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179007:ccn:235536

  View official CMS source

• F0921 — Environmental Deficiencies

  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179008:ccn:235536

  View official CMS source

• F0925 — Environmental Deficiencies

  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

  Correction status: Deficient, Provider has date of correction (Jan 31, 2023)

  View source details

  Dataset

  Health Deficiencies

  CMS dataset ID

  r5ix-sfxw

  CMS source updated

  Jul 1, 2026

  CMS provider ID

  235536

  Source record locator

  csv-row:179009:ccn:235536

  View official CMS source