| F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 11, 2024 |
| F576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 11, 2024 |
| F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 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 · June 20, 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 · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 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 · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| 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 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| 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 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 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 · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 11, 2024 |
| F558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 11, 2024 |
| 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 · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 · May 10, 2024 |
| 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 · May 10, 2024 |
| F641 | Ensure each resident receives an accurate 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 · May 10, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 · May 10, 2024 |
| F699 | Provide care or services that was trauma informed and/or culturally competent. 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 · May 10, 2024 |
| 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 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F791 | Provide or obtain dental services for each resident. 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 · May 10, 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 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| 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 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 10, 2024 |
| F881 | Implement a program that monitors antibiotic use. 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 · May 10, 2024 |