| F806 | 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 · Standard survey · Cycle 1 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · August 22, 2025 |
| F580 | 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 · Complaint survey · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 22, 2025 |
| F645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 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 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| 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 · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 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 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 22, 2025 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |
| F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 22, 2025 |