| 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 · Standard survey · Cycle 1 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · April 24, 2025 |
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · April 24, 2025 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · April 24, 2025 |
| F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| 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 · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 · April 24, 2025 |
| F558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F646 | Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. 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 · April 24, 2025 |
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |
| F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 24, 2025 |