| 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 · Complaint survey · Standard survey · Cycle 1 | L: widespread, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · October 13, 2023 |
| 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 · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · October 19, 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 · Complaint survey · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · October 19, 2023 |
| 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 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · September 27, 2023 |
| F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · October 12, 2023 |
| 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 · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · September 22, 2023 |
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Complaint survey · Standard survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · October 19, 2023 |
| F802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 16, 2023 |
| F569 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. 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 · October 19, 2023 |
| F685 | Assist a resident in gaining access to vision and hearing services. 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 · October 18, 2023 |
| F687 | Provide appropriate foot care. 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 · October 18, 2023 |
| F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 · October 19, 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 · October 18, 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 · October 10, 2023 |
| 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 · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 12, 2023 |
| 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 · September 28, 2023 |