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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Apr 18, 2023	17	0	0	17	Read full report
Deficiencies cited in this report: GOVERNING BODY CHIEF EXECUTIVE OFFICER PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY QAPI EXECUTIVE RESPONSIBILITIES NURSING SERVICES ORGANIZATION OF NURSING SERVICES STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS
Jun 6, 2022 Follow-up to inspection on 2022-04-26*	2	0	0	2	Read full report
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE
Apr 26, 2022	8	0	0	8	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE SURGICAL SERVICES OPERATING ROOM POLICIES
Apr 3, 2018 Follow-up to inspection on 2018-02-14*	1	0	0	1	Read full report
Deficiencies cited in this report: PHARMACIST SUPERVISION OF SERVICES
Feb 14, 2018 Follow-up to inspection on 2017-12-20*	1	0	0	1	Read full report
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT
Feb 14, 2018	2	0	0	2	Read full report
Deficiencies cited in this report: Condition of Participation: Pharmaceutical Se PHARMACIST SUPERVISION OF SERVICES
Dec 20, 2017	4	0	0	4	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT
Feb 19, 2015	5	0	0	5	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING NURSING SERVICES RN SUPERVISION OF NURSING CARE NURSING CARE PLAN
Nov 25, 2014 Follow-up to inspection on 2014-08-05*	1	0	0	1	Read full report
Deficiencies cited in this report: PHARMACIST SUPERVISION OF SERVICES
Nov 25, 2014 Follow-up to inspection on 2014-10-21*	1	0	0	1	Read full report
Deficiencies cited in this report: PHARMACIST SUPERVISION OF SERVICES
Oct 21, 2014	13	0	0	13	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION MEDICAL STAFF RESPONSIBILITIES - H&P RN SUPERVISION OF NURSING CARE PHARMACIST SUPERVISION OF SERVICES SECURE STORAGE FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROGRAM POST-ANESTHESIA EVALUATION QUALIFIED EMERGENCY SERVICES PERSONNEL DELIVERY OF SERVICES
Oct 21, 2014	0	5	0	5	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available
Aug 5, 2014	12	0	0	12	Read full report
Deficiencies cited in this report: GOVERNING BODY CONTRACTED SERVICES QAPI QUALITY IMPROVEMENT ACTIVITIES Standard-level Tag for Pharmaceutical Service PHARMACIST RESPONSIBILITIES PHARMACIST SUPERVISION OF SERVICES PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM
Jul 2, 2012	17	0	0	17	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION MEDICAL STAFF MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY RN SUPERVISION OF NURSING CARE NURSING CARE PLAN PHARMACY DRUG RECORDS MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROGRAM INTRAOPERATIVE ANESTHESIA RECORD POST-ANESTHESIA EVALUATION RESPIRATORY CARE SERVICES RESPIRATORY CARE SERVICES POLICIES ORDERS FOR RESPIRATORY SERVICES
Jul 2, 2012	0	12	0	12	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available
May 22, 2012	12	0	0	12	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: EXERCISE OF RIGHTS PATIENT RIGHTS: INFORMED DECISION PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION RN SUPERVISION OF NURSING CARE NURSING CARE PLAN No Description Available FORM AND RETENTION OF RECORDS
Dec 15, 2011	4	0	0	4	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE PROTECTING PATIENT RECORDS SECURE STORAGE OPERATIVE REPORT
Dec 15, 2011	0	3	0	3	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available
Oct 25, 2011	7	0	0	7	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION QAPI No Description Available FORM AND RETENTION OF RECORDS CONTENT OF RECORD: DISCHARGE SUMMARY EMERGENCY SERVICES EMERGENCY SERVICES POLICIES
Aug 9, 2010 Follow-up to inspection on 2010-06-29*	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE No Description Available
Jun 29, 2010	11	0	0	11	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION No Description Available MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY RN SUPERVISION OF NURSING CARE NURSING CARE PLAN No Description Available FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROGRAM REASSESSMENT OF A DISCHARGE PLAN
Jun 29, 2010	0	1	0	1	Read full report
Deficiencies cited in this report: No Description Available
May 12, 2010	7	0	0	7	Read full report
Deficiencies cited in this report: GOVERNING BODY MEDICAL STAFF - ACCOUNTABILITY No Description Available MEDICAL STAFF MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY ORGANIZATION OF MEDICAL STAFF CONTENT OF RECORD
Mar 9, 2010 Follow-up to inspection (date unspecified)*	2	0	0	2	Read full report
Deficiencies cited in this report: NURSING SERVICES No Description Available

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

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Complete reports and deficiency counts