| 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 · Standard survey · Cycle 3 | K: pattern, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · April 23, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 3 | K: pattern, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · April 23, 2024 |
| F760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Complaint survey · Standard survey · Cycle 3 | K: pattern, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · April 23, 2024 |
| F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Past Non-Compliance · February 15, 2024 |
| F660 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Complaint survey · Standard survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · April 23, 2024 |
| 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 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · April 23, 2024 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · April 23, 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 · Standard survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · April 23, 2024 |
| F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Past Non-Compliance · December 20, 2023 |
| F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 23, 2024 |
| F641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 23, 2024 |
| F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 23, 2024 |
| 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 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 23, 2024 |
| 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 3 | D: isolated, no actual harm, with potential for more than minimal harm | Past Non-Compliance · December 20, 2023 |