D
F-550
no actual harm; potential for more than minimal harm · isolated
Residents weren't treated with dignity or weren't allowed to make their own choices.
CMS requirement: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected Jul 15, 2023
D
F-607
no actual harm; potential for more than minimal harm · isolated
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.
Corrected Jul 15, 2023
D
F-609
no actual harm; potential for more than minimal harm · isolated
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 15, 2023
D
F-610
no actual harm; potential for more than minimal harm · isolated
Reported abuse or neglect allegations weren't properly investigated or acted on.
CMS requirement: Respond appropriately to all alleged violations.
Corrected Jul 15, 2023
D
F-641
no actual harm; potential for more than minimal harm · isolated
Resident health assessments were inaccurate.
CMS requirement: Ensure each resident receives an accurate assessment.
Corrected Jul 15, 2023
D
F-656
no actual harm; potential for more than minimal harm · isolated
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 15, 2023
E
F-658
no actual harm; potential for more than minimal harm · pattern
Care provided didn't meet professional standards of quality.
CMS requirement: Ensure services provided by the nursing facility meet professional standards of quality.
Corrected Jul 15, 2023
E
F-684
no actual harm; potential for more than minimal harm · pattern
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 15, 2023
D
F-695
no actual harm; potential for more than minimal harm · isolated
Oxygen, breathing treatments, or other respiratory care wasn't handled safely or appropriately.
CMS requirement: Provide safe and appropriate respiratory care for a resident when needed.
Corrected Jul 15, 2023
D
F-697
no actual harm; potential for more than minimal harm · isolated
Pain wasn't managed safely or appropriately.
CMS requirement: Provide safe, appropriate pain management for a resident who requires such services.
Corrected Jul 15, 2023
E
F-760
no actual harm; potential for more than minimal harm · pattern
A resident experienced a significant medication error.
CMS requirement: Ensure that residents are free from significant medication errors.
Corrected Jul 15, 2023
E
F-761
no actual harm; potential for more than minimal harm · pattern
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 Jul 15, 2023
E
F-812
no actual harm; potential for more than minimal harm · pattern
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 15, 2023
F
F-868
no actual harm; potential for more than minimal harm · widespread
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected Jul 15, 2023
D
F-880
no actual harm; potential for more than minimal harm · isolated
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 15, 2023