| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Complaint survey · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · August 5, 2025 |
| F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · August 5, 2025 |
| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · August 6, 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 · Complaint survey · Standard survey · Cycle 1 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · August 5, 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 · 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 5, 2025 |
| F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration 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 5, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control 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 5, 2025 |
| F881 | Implement a program that monitors antibiotic use. Infection Control 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 5, 2025 |
| F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control 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 5, 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 · 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 5, 2025 |
| F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental 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 5, 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 · Complaint survey · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 5, 2025 |
| F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Complaint survey · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 5, 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 · Complaint survey · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 5, 2025 |
| F814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Complaint survey · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 5, 2025 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. 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 5, 2025 |
| F554 | Allow residents to self-administer drugs if determined clinically appropriate. 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 5, 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 5, 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 · 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 5, 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 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 5, 2025 |
| 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 · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 5, 2025 |
| F610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation 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 5, 2025 |
| F641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning 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 5, 2025 |
| F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning 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 5, 2025 |
| F692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care 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 5, 2025 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care 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 5, 2025 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service 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 5, 2025 |
| F568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 1 | C: widespread, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · August 5, 2025 |