D
F-836
no actual harm; potential for more than minimal harm · isolated
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected Jan 11, 2025
D
F-580
no actual harm; potential for more than minimal harm · isolated · found via complaint
The home didn't promptly tell the resident, their doctor, or family about an injury, decline, or other significant change.
CMS requirement: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Oct 15, 2024
D
F-607
no actual harm; potential for more than minimal harm · isolated · found via complaint
The home's written policies to prevent abuse, neglect, and theft were missing or not followed.
CMS requirement: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No correction date on file
D
F-609
no actual harm; potential for more than minimal harm · isolated · found via complaint
Suspected abuse, neglect, or theft wasn't reported to authorities on time.
CMS requirement: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No correction date on file
D
F-623
no actual harm; potential for more than minimal harm · isolated · found via complaint
Residents weren't properly notified before a transfer or discharge, including their right to appeal.
CMS requirement: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected Jan 11, 2025
D
F-625
no actual harm; potential for more than minimal harm · isolated · found via complaint
Residents weren't told in writing how long their bed would be held during a hospital stay.
CMS requirement: Notify 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.
Corrected Jan 11, 2025
D
F-641
no actual harm; potential for more than minimal harm · isolated · found via complaint
Resident health assessments were inaccurate.
CMS requirement: Ensure each resident receives an accurate assessment.
Corrected Oct 15, 2024
D
F-657
no actual harm; potential for more than minimal harm · isolated · found via complaint
Care plans weren't finished within 7 days of assessment, or weren't built and reviewed by the right team.
CMS requirement: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Oct 15, 2024
D
F-658
no actual harm; potential for more than minimal harm · isolated · found via complaint
Care provided didn't meet professional standards of quality.
CMS requirement: Ensure services provided by the nursing facility meet professional standards of quality.
Corrected Oct 15, 2024
D
F-684
no actual harm; potential for more than minimal harm · isolated · found via complaint
Residents didn't get treatment or care the way their doctors ordered or their care goals called for.
CMS requirement: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Oct 15, 2024
D
F-685
no actual harm; potential for more than minimal harm · isolated · found via complaint
Assist a resident in gaining access to vision and hearing services.
Corrected Oct 15, 2024
J
F-689
immediate jeopardy to resident health or safety · isolated · found via complaint
Inspectors found accident hazards, or residents weren't supervised closely enough to prevent falls and injuries.
CMS requirement: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Jan 11, 2025
D
F-697
no actual harm; potential for more than minimal harm · isolated · found via complaint
Pain wasn't managed safely or appropriately.
CMS requirement: Provide safe, appropriate pain management for a resident who requires such services.
Corrected Oct 15, 2024
F
F-725
no actual harm; potential for more than minimal harm · widespread · found via complaint
Not enough nursing staff on duty to meet residents' needs.
CMS requirement: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected Oct 15, 2024
E
F-726
no actual harm; potential for more than minimal harm · pattern · found via complaint
Nurses and aides lacked the demonstrated skills to care for their residents.
CMS requirement: 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.
Corrected Oct 15, 2024
E
F-755
no actual harm; potential for more than minimal harm · pattern · found via complaint
Pharmacy services fell short — the facility didn't properly use a licensed pharmacist to manage medications.
CMS requirement: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Jan 11, 2025
D
F-756
no actual harm; potential for more than minimal harm · isolated · found via complaint
Monthly pharmacist reviews of each resident's medications didn't happen or irregularities weren't reported.
CMS requirement: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected Oct 15, 2024
D
F-759
no actual harm; potential for more than minimal harm · isolated · found via complaint
The overall medication error rate was 5% or higher.
CMS requirement: Ensure medication error rates are not 5 percent or greater.
Corrected Oct 15, 2024
D
F-761
no actual harm; potential for more than minimal harm · isolated · found via complaint
Medications weren't labeled or locked up the way pharmacy rules require.
CMS requirement: 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.
Corrected Oct 15, 2024
D
F-790
no actual harm; potential for more than minimal harm · isolated · found via complaint
Provide routine and 24-hour emergency dental care for each resident.
Corrected Oct 15, 2024
E
F-812
no actual harm; potential for more than minimal harm · pattern · found via complaint
Problems with safe food handling — storage temperatures, kitchen sanitation, or food from unapproved sources.
CMS requirement: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Oct 15, 2024
D
F-880
no actual harm; potential for more than minimal harm · isolated · found via complaint
The home didn't follow infection prevention and control rules — things like hand hygiene, isolation precautions, or tracking infections.
CMS requirement: Provide and implement an infection prevention and control program.
Corrected Oct 15, 2024
D
F-887
no actual harm; potential for more than minimal harm · isolated · found via complaint
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected Oct 15, 2024
E
F-908
no actual harm; potential for more than minimal harm · pattern · found via complaint
Essential equipment wasn't kept in safe working order.
CMS requirement: Keep all essential equipment working safely.
Corrected Oct 15, 2024