| F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Complaint survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 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 · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| 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 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| 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 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 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 · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F563 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 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 · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 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 · October 18, 2024 |
| F660 | Plan the resident's discharge to meet the resident's goals and needs. 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 · October 18, 2024 |
| F676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 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 · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 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 · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · October 18, 2024 |
| 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 · October 18, 2024 |
| F814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 2 | C: widespread, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · October 18, 2024 |