| F801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 21, 2024 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 18, 2024 |
| F836 | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 27, 2024 |
| F944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F946 | Provide training in compliance and ethics. Administration Deficiencies · Standard survey · Cycle 3 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 24, 2024 |
| F941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 2024 |
| F949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 25, 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 · June 12, 2024 |