CCN 676053

Merkel Nursing Center

1704 N. 1st, Merkel, TX 79536 · Taylor County

Phone: (325) 928-5673
Ownership: For profit - Limited Liability company
Certified beds: 65
Residents per day: 18.7
Health citations: 64
Penalties: 2
Fines: 2 · $318,060
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 1 · short-stay —.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

CMS special focus status: SFF Candidate. This facility is not rated due to a history of serious quality issues and is included in the Special Focus Facility program.

CMS has turned on the abuse icon. The September 2026 Technical Users' Guide applies that icon for abuse tags F600, F602, or F603: a citation at scope and severity G or higher on the most recent standard survey or on a complaint or focused infection-control survey in the past 12 months, or a repeat citation at D or higher across the recent windows described in the guide. While the icon is on, the health inspection rating is capped at two stars.

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.09; 2.01; 2.32
LPN/LVN: 1.58; 0.95; 0.86
Registered nurse: 0.68; 0.43; 0.69
Total nurse staff: 3.35; 3.39; 3.86
Weekend total: 2.52; 2.98; 3.42
Weekend RN: 0.67; 0.34; 0.48

Adjusted total nurse hours: 3.88. Adjusted RN hours: 0.79. Case-mix total: 3.31. Case-mix index: 1.211.

Total nursing staff turnover: 71.1%. RN turnover: —. Administrators who left: 0.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 2 fines totaling $318,060, and 0 payment denials.

Date	Type	Amount or days
February 16, 2026	Fine	$137,108
August 22, 2025	Fine	$180,952

Cycle 1 standard survey: December 4, 2025. Health deficiencies counted in cycle 1: 21. Cycle 1 total health score: 618.

Cycle 2 standard survey: July 31, 2024. Cycle 2/3 health deficiencies: 35. Total weighted health survey score: 550.75.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 64 citations for this home, including 5 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

February 16, 2026

8 citations

Tag	What CMS cited	Scope and severity	Status
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 1	K: pattern, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · March 4, 2026
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 · Cycle 1	K: pattern, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · March 4, 2026
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 1	K: pattern, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · March 4, 2026
F726	Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 1	K: pattern, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · March 4, 2026
F727	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 4, 2026
F728	Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Nursing and Physician Services Deficiencies · Complaint survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 4, 2026
F881	Implement a program that monitors antibiotic use. Infection Control Deficiencies · Complaint survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 4, 2026
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 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · March 4, 2026

December 4, 2025

13 citations

Tag	What CMS cited	Scope and severity	Status
F867	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Standard survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F849	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F909	Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F940	Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F941	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
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 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
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 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F944	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
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 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
F949	Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
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 · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 7, 2026
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 · January 7, 2026

August 22, 2025

8 citations

Tag	What CMS cited	Scope and severity	Status
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 · Cycle 2	K: pattern, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · September 1, 2025
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 · Complaint survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 25, 2025
F835	Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Complaint survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 2025
F838	Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · Complaint survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2025
F607	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 17, 2025
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 · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 17, 2025
F610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 17, 2025
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 2	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 18, 2025

December 12, 2024

1 citation

Tag	What CMS cited	Scope and severity	Status
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 1, 2025

October 17, 2024

6 citations

Tag	What CMS cited	Scope and severity	Status
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 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 8, 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 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 8, 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 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 8, 2024
F926	Have policies on smoking. Environmental Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 8, 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 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 8, 2024
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 · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 8, 2024

July 31, 2024

19 citations

Tag	What CMS cited	Scope and severity	Status
F868	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 2024
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 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 5, 2024
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 5, 2024
F728	Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Nursing and Physician Services Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 2024
F803	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 2, 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 · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 2, 2024
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 2, 2024
F909	Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 20, 2024
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 2024
F607	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 2024
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 2024
F576	Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 2	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · August 31, 2024
F680	Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · August 19, 2024
F732	Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024
F941	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024
F944	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024
F949	Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024

December 15, 2023

1 citation

Tag	What CMS cited	Scope and severity	Status
F908	Keep all essential equipment working safely. Environmental Deficiencies · Complaint survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 20, 2023

June 8, 2023

8 citations

Tag	What CMS cited	Scope and severity	Status
F558	Reasonably accommodate the needs and preferences of each resident. 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 · July 7, 2023
F567	Honor the resident's right to manage his or her financial affairs. 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 · July 7, 2023
F711	Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. 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 · July 7, 2023
F727	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 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 · July 7, 2023
F761	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 7, 2023
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	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 7, 2023
F868	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 7, 2023
F880	Provide and implement an infection prevention and control 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 · July 7, 2023

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Legal business name: Emi Healthcare LLC.
First approved for Medicare and Medicaid services: June 1, 2005.
Resident and family council: None.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Merkel Nursing Center?

Merkel Nursing Center has an overall rating of 1 out of 5. The health inspection rating is 1, staffing is 3, and the quality measure rating is 1.

How many health citations does CMS list for Merkel Nursing Center?

The Health Deficiencies file lists 64 health citations for this home. 5 are coded immediate jeopardy (J, K, or L) and 0 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Merkel Nursing Center?

CMS reports 3.35 total nurse hours per resident per day, including 0.68 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

July 31, 2024

19 citations

Tag	What CMS cited	Scope and severity	Status
F868	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 2024
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 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 5, 2024
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 5, 2024
F728	Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Nursing and Physician Services Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 2024
F803	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 2, 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 · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 2, 2024
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 2, 2024
F909	Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 20, 2024
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 2024
F607	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 15, 2024
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 1, 2024
F576	Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Complaint survey · Standard survey · Cycle 2	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · August 31, 2024
F680	Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · August 19, 2024
F732	Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024
F941	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024
F944	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024
F949	Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	B: pattern, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · September 5, 2024