| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 3 | L: widespread, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · July 11, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · July 11, 2024 |
| F622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 11, 2024 |
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 11, 2024 |
| F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 11, 2024 |
| F697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 11, 2024 |
| F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F844 | Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Administration Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Complaint survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 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 · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| 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 · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F660 | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |
| F881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 11, 2024 |