| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 3 | L: widespread, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · May 29, 2024 |
| F837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies · Complaint survey · Cycle 3 | L: widespread, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · May 29, 2024 |
| F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Complaint survey · Cycle 3 | L: widespread, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · May 29, 2024 |
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · May 29, 2024 |
| F803 | 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 · Complaint survey · Cycle 3 | I: widespread, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · September 16, 2024 |
| F600 | 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 · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 17, 2024 |
| F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 17, 2024 |
| F692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · September 16, 2024 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 16, 2024 |
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 29, 2024 |
| F908 | Keep all essential equipment working safely. Environmental Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 16, 2024 |
| F583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 16, 2024 |
| F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 29, 2024 |
| F558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 29, 2024 |
| F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 17, 2024 |
| F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 29, 2024 |