Mirage Post Acute

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has no plan of correction

DMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Complaint inspection · Deficient, Provider has date of correction (Aug 18, 2026)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Jul 16, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Jul 8, 2026)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Complaint inspection · Deficient, Provider has date of correction (Jul 8, 2026)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2026)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2026)

DEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0627 · Complaint inspection · Deficient, Provider has date of correction (Jun 18, 2026)

DGive the resident's representative the ability to exercise the resident's rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0551 · Complaint inspection · Deficient, Provider has date of correction (Jun 12, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Jun 5, 2026)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Jun 5, 2026)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Jun 5, 2026)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (May 11, 2026)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (May 11, 2026)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (May 15, 2026)

EEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 · Deficient, Provider has date of correction (May 15, 2026)

EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (May 15, 2026)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (May 15, 2026)

EProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (May 15, 2026)

EProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (May 15, 2026)

ETry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (May 15, 2026)

EEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (May 15, 2026)

EEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (May 15, 2026)

EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (May 15, 2026)

EImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Deficient, Provider has date of correction (May 15, 2026)

EKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Deficient, Provider has date of correction (May 15, 2026)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (May 15, 2026)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (May 15, 2026)

DPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605 · Deficient, Provider has date of correction (May 15, 2026)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (May 15, 2026)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (May 15, 2026)

DEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (May 15, 2026)

DAssist a resident in gaining access to vision and hearing services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0685 · Deficient, Provider has date of correction (May 15, 2026)

DProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Deficient, Provider has date of correction (May 15, 2026)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (May 15, 2026)

DProvide routine and 24-hour emergency dental care for each resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0790 · Deficient, Provider has date of correction (May 15, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (May 15, 2026)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Mar 16, 2026)

DMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Complaint inspection · Deficient, Provider has date of correction (Feb 4, 2026)

EPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

EProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Mar 2, 2026)

EMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0925 · Complaint inspection · Deficient, Provider has date of correction (Feb 19, 2026)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Feb 19, 2026)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Dec 24, 2025)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Nov 26, 2025)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Nov 25, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Nov 25, 2025)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Nov 25, 2025)

EHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2025)

DMake sure that a working call system is available in each resident's bathroom and bathing area.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0919 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2025)

DMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2025)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Sep 19, 2025)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Sep 19, 2025)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Sep 19, 2025)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Complaint inspection · Deficient, Provider has date of correction (Sep 19, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Sep 19, 2025)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Sep 26, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Sep 3, 2025)

DProvide activities to meet all resident's needs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0679 · Complaint inspection · Deficient, Provider has date of correction (Sep 3, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Sep 3, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Sep 3, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Aug 28, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Aug 8, 2025)

EProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has date of correction (Jul 31, 2025)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jul 31, 2025)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Jul 31, 2025)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Jul 31, 2025)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jun 23, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jun 8, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Jun 8, 2025)

DProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Jun 8, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jun 8, 2025)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Apr 27, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Apr 27, 2025)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Apr 27, 2025)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Apr 27, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Apr 27, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Apr 27, 2025)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Apr 21, 2025)

EEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Apr 1, 2025)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Apr 1, 2025)

EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Mar 13, 2025)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Mar 13, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Mar 13, 2025)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Mar 30, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Mar 30, 2025)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Feb 28, 2025)

DEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Complaint inspection · Deficient, Provider has date of correction (Feb 28, 2025)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Complaint inspection · Deficient, Provider has date of correction (Feb 5, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Feb 5, 2025)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Jan 30, 2025)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Jan 30, 2025)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jan 30, 2025)

EPost nurse staffing information every day.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0732 · Complaint inspection · Deficient, Provider has date of correction (Jan 25, 2025)

EEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Jan 25, 2025)

EMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Complaint inspection · Deficient, Provider has date of correction (Jan 25, 2025)

EReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 · Deficient, Provider has date of correction (Feb 5, 2025)

EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (Feb 5, 2025)

EProvide for the safe, appropriate administration of IV fluids for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0694 · Complaint inspection · Deficient, Provider has date of correction (Feb 5, 2025)

ETry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (Feb 5, 2025)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Feb 5, 2025)

EImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Feb 5, 2025)

EProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0802 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0804 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0805 · Deficient, Provider has date of correction (Feb 5, 2025)

EEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0808 · Deficient, Provider has date of correction (Feb 5, 2025)

EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Feb 5, 2025)

EDispose of garbage and refuse properly.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0814 · Deficient, Provider has date of correction (Feb 5, 2025)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Feb 5, 2025)

DAllow residents to self-administer drugs if determined clinically appropriate.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0554 · Deficient, Provider has date of correction (Feb 5, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Feb 5, 2025)

DEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Deficient, Provider has date of correction (Feb 5, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Feb 5, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Feb 5, 2025)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Feb 5, 2025)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Deficient, Provider has date of correction (Feb 5, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jan 20, 2025)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jan 24, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Jan 24, 2025)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Complaint inspection · Deficient, Provider has date of correction (Jan 24, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Jan 24, 2025)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Jan 9, 2025)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Jan 9, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Jan 9, 2025)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Jan 9, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Dec 28, 2024)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Dec 21, 2024)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Dec 16, 2024)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Dec 16, 2024)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Dec 16, 2024)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2024)

DProvide for the safe, appropriate administration of IV fluids for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0694 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Nov 30, 2024)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2024)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2024)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2024)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2024)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide activities to meet all resident's needs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0679 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Oct 22, 2024)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Complaint inspection · Deficient, Provider has date of correction (Oct 22, 2024)

EProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DProvide activities to meet all resident's needs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0679 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Oct 18, 2024)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Sep 23, 2024)

DEnsure that residents are fully informed and understand their health status, care and treatments.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Complaint inspection · Deficient, Provider has date of correction (Aug 20, 2024)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Aug 20, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jul 17, 2024)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (May 24, 2024)

DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Complaint inspection · Deficient, Provider has date of correction (May 24, 2024)

DEnsure 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.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0728 · Complaint inspection · Deficient, Provider has date of correction (May 24, 2024)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (May 10, 2024)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Complaint inspection · Deficient, Provider has date of correction (May 10, 2024)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Apr 25, 2024)

EHonor each resident's preferences, choices, values and beliefs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0675 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

EKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

DProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

DEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Apr 4, 2024)

EHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure that residents are fully informed and understand their health status, care and treatments.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0552 · Deficient, Provider has date of correction (Feb 23, 2024)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 · Deficient, Provider has date of correction (Feb 23, 2024)

EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide for the safe, appropriate administration of IV fluids for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0694 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide safe, appropriate pain management for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide medically-related social services to help each resident achieve the highest possible quality of life.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0745 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Deficient, Provider has date of correction (Feb 23, 2024)

EImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (Feb 23, 2024)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Feb 23, 2024)

EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Feb 23, 2024)

EArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Feb 23, 2024)

DAllow resident to participate in the development and implementation of his or her person-centered plan of care.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0553 · Deficient, Provider has date of correction (Feb 23, 2024)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Feb 23, 2024)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Feb 23, 2024)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Deficient, Provider has date of correction (Feb 23, 2024)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (Feb 23, 2024)

DNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (Feb 23, 2024)

DCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0655 · Deficient, Provider has date of correction (Feb 23, 2024)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Feb 23, 2024)

DPlan the resident's discharge to meet the resident's goals and needs.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0660 · Deficient, Provider has date of correction (Feb 23, 2024)

DProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0678 · Deficient, Provider has date of correction (Feb 23, 2024)

DAssist a resident in gaining access to vision and hearing services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0685 · Deficient, Provider has date of correction (Feb 23, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Feb 23, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Feb 23, 2024)

DEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0693 · Deficient, Provider has date of correction (Feb 23, 2024)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Feb 23, 2024)

DProvide or obtain dental services for each resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0791 · Complaint inspection · Deficient, Provider has date of correction (Feb 23, 2024)

DEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0809 · Deficient, Provider has date of correction (Feb 23, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Deficient, Provider has date of correction (Feb 23, 2024)

DKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Deficient, Provider has date of correction (Feb 23, 2024)

EProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2024)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2024)

DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2024)

DHire a qualified full-time social worker in a facility with more than 120 beds.

Potential for more than minimal harm · Administration Deficiencies · Tag F0850 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2024)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Feb 2, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2023)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2023)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2023)

DPost nurse staffing information every day.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0732 · Complaint inspection · Deficient, Provider has date of correction (Dec 12, 2023)

EEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2023)

EEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0804 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2023)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2023)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2023)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Dec 2, 2023)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Nov 16, 2023)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Nov 16, 2023)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Nov 16, 2023)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2023)

DProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Potential for more than minimal harm · Administration Deficiencies · Tag F0773 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2023)

DReport COVID19 data to residents and families.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0885 · Complaint inspection · Deficient, Provider has date of correction (Nov 20, 2023)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Nov 2, 2023)

DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0585 · Complaint inspection · Deficient, Provider has date of correction (Nov 2, 2023)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Oct 17, 2023)