| 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 · Standard survey · Cycle 2 · Under IIDR | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has plan of correction · February 12, 2025 |
| F678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 · Under IIDR | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has plan of correction · February 12, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2 · Under IIDR | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F887 | 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. Infection Control Deficiencies · Standard survey · Cycle 2 · Under IIDR | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Environmental Deficiencies · Standard survey · Cycle 2 · Under IIDR | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| 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 · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F761 | 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 · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| 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 · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| 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 · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F836 | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F911 | 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 · Standard survey · Cycle 2 · Under IIDR | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Standard survey · Cycle 2 · Under IIDR | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F578 | 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. Resident Rights Deficiencies · Standard survey · Cycle 2 · Under IIDR | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 · Under IIDR | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 · Under IIDR | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |
| F805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has plan of correction · February 12, 2025 |