| 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 2 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · September 8, 2022 |
| 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 2 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · September 8, 2022 |
| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Standard survey · Cycle 2 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · September 8, 2022 |
| 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 2 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · September 8, 2022 |
| F700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |
| 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 · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |
| F638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |
| F640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |
| F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |
| F888 | Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 8, 2022 |