| 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 12, 2023 |
| F881 | Implement a program that monitors antibiotic use. 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 12, 2023 |
| 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 · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 12, 2023 |
| F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 12, 2023 |
| F624 | Prepare residents for a safe transfer or discharge from the nursing home. 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 12, 2023 |
| 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 12, 2023 |
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 12, 2023 |
| 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 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 12, 2023 |
| F693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. 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 12, 2023 |
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 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 12, 2023 |
| 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 12, 2023 |
| F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 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 12, 2023 |
| F791 | Provide or obtain dental services for each resident. 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 12, 2023 |
| F730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Standard survey · Cycle 1 | C: widespread, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · August 12, 2023 |