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 May 12, 2023
E
F-584
no actual harm; potential for more than minimal harm · pattern
The building or rooms weren't kept safe, clean, comfortable, and homelike.
CMS requirement: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected May 12, 2023
E
F-607
no actual harm; potential for more than minimal harm · pattern
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 May 12, 2023
E
F-610
no actual harm; potential for more than minimal harm · pattern
Reported abuse or neglect allegations weren't properly investigated or acted on.
CMS requirement: Respond appropriately to all alleged violations.
Corrected May 12, 2023
D
F-623
no actual harm; potential for more than minimal harm · isolated
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 May 12, 2023
D
F-625
no actual harm; potential for more than minimal harm · isolated
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 May 12, 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 May 12, 2023
D
F-655
no actual harm; potential for more than minimal harm · isolated
No baseline care plan covering immediate needs within 48 hours of admission.
CMS requirement: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 12, 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 May 12, 2023
D
F-657
no actual harm; potential for more than minimal harm · isolated
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 May 12, 2023
E
F-756
no actual harm; potential for more than minimal harm · pattern
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 May 12, 2023
D
F-842
no actual harm; potential for more than minimal harm · isolated
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 May 12, 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 May 12, 2023
D
F-883
no actual harm; potential for more than minimal harm · isolated
Flu and pneumonia vaccination policies were missing or not followed.
CMS requirement: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected May 12, 2023
D
F-887
no actual harm; potential for more than minimal harm · isolated
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 May 12, 2023