D
F-554
no actual harm; potential for more than minimal harm · isolated · found via complaint
Residents clinically able to manage their own medications weren't allowed to.
CMS requirement: Allow residents to self-administer drugs if determined clinically appropriate.
Corrected Jul 28, 2025
E
F-578
no actual harm; potential for more than minimal harm · pattern · found via complaint
Residents' rights to refuse treatment or set advance directives weren't honored.
CMS requirement: 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.
Corrected Jul 28, 2025
D
F-600
no actual harm; potential for more than minimal harm · isolated · found via complaint
A failure to protect residents from abuse, neglect, or physical punishment.
CMS requirement: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Jul 28, 2025
D
F-604
no actual harm; potential for more than minimal harm · isolated · found via complaint
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected Jul 28, 2025
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.
Corrected Jul 28, 2025
D
F-610
no actual harm; potential for more than minimal harm · isolated · found via complaint
Reported abuse or neglect allegations weren't properly investigated or acted on.
CMS requirement: Respond appropriately to all alleged violations.
Corrected Jul 28, 2025
E
F-656
no actual harm; potential for more than minimal harm · pattern · found via complaint
Care plans were missing pieces — not every need a resident has was written into a measurable plan.
CMS requirement: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected Jul 28, 2025
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 Jul 28, 2025
D
F-677
no actual harm; potential for more than minimal harm · isolated · found via complaint
Residents who need help with daily basics — bathing, dressing, eating, hygiene — didn't get that help.
CMS requirement: Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Jul 28, 2025
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 Jul 28, 2025
G
F-686
actual harm · isolated · found via complaint
Pressure ulcer (bedsore) care fell short — existing sores weren't treated properly or new ones weren't prevented.
CMS requirement: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Jul 28, 2025
K
F-689
immediate jeopardy to resident health or safety · pattern · 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 Jul 28, 2025
D
F-693
no actual harm; potential for more than minimal harm · isolated · found via complaint
Feeding tubes were used without medical justification or consent, or tube care fell short.
CMS requirement: Ensure 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.
Corrected Jul 28, 2025
D
F-694
no actual harm; potential for more than minimal harm · isolated · found via complaint
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected Jul 28, 2025
D
F-711
no actual harm; potential for more than minimal harm · isolated · found via complaint
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected Jul 28, 2025
D
F-726
no actual harm; potential for more than minimal harm · isolated · 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 Jul 28, 2025
D
F-755
no actual harm; potential for more than minimal harm · isolated · 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 Jul 28, 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 Jul 28, 2025
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 Jul 28, 2025
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 Aug 4, 2025
D
F-805
no actual harm; potential for more than minimal harm · isolated · found via complaint
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected Jul 28, 2025
D
F-812
no actual harm; potential for more than minimal harm · isolated · 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 Jul 28, 2025
D
F-836
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Jul 28, 2025
D
F-842
no actual harm; potential for more than minimal harm · isolated · found via complaint
Medical records were incomplete, inaccurate, or not kept confidential.
CMS requirement: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected Jul 28, 2025
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 Jul 28, 2025
D
F-925
no actual harm; potential for more than minimal harm · isolated · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected Jul 28, 2025
F
F-942
no actual harm; potential for more than minimal harm · widespread · found via complaint
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected Jul 28, 2025
F
F-944
no actual harm; potential for more than minimal harm · widespread · found via complaint
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected Jul 28, 2025
F
F-946
no actual harm; potential for more than minimal harm · widespread · found via complaint
Provide training in compliance and ethics.
Corrected Jul 28, 2025
F
F-947
no actual harm; potential for more than minimal harm · widespread · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected Jul 28, 2025
F
F-949
no actual harm; potential for more than minimal harm · widespread · found via complaint
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected Jul 28, 2025