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 Feb 23, 2022
D
F-558
no actual harm; potential for more than minimal harm · isolated
The home didn't reasonably accommodate residents' needs and preferences.
CMS requirement: Reasonably accommodate the needs and preferences of each resident.
Corrected Feb 23, 2022
D
F-576
no actual harm; potential for more than minimal harm · isolated
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected Feb 23, 2022
D
F-578
no actual harm; potential for more than minimal harm · isolated
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 Feb 23, 2022
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 Feb 23, 2022
D
F-600
no actual harm; potential for more than minimal harm · isolated
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 Feb 23, 2022
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 Feb 23, 2022
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 Feb 23, 2022
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 Feb 23, 2022
D
F-622
no actual harm; potential for more than minimal harm · isolated
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected Feb 23, 2022
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 Feb 23, 2022
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 Feb 23, 2022
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 Feb 23, 2022
D
F-645
no actual harm; potential for more than minimal harm · isolated
Required screening for mental illness or intellectual disability before admission didn't happen.
CMS requirement: PASARR screening for Mental disorders or Intellectual Disabilities
Corrected Feb 23, 2022
E
F-656
no actual harm; potential for more than minimal harm · pattern
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 Feb 23, 2022
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 Feb 23, 2022
D
F-660
no actual harm; potential for more than minimal harm · isolated
Plan the resident's discharge to meet the resident's goals and needs.
Corrected Feb 23, 2022
D
F-677
no actual harm; potential for more than minimal harm · isolated
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 Feb 23, 2022
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 Feb 23, 2022
D
F-685
no actual harm; potential for more than minimal harm · isolated
Assist a resident in gaining access to vision and hearing services.
Corrected Feb 23, 2022
E
F-686
no actual harm; potential for more than minimal harm · pattern
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 Feb 23, 2022
E
F-688
no actual harm; potential for more than minimal harm · pattern
Residents didn't get care to maintain mobility and range of motion.
CMS requirement: Provide 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.
Corrected Feb 23, 2022
E
F-689
no actual harm; potential for more than minimal harm · pattern
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 Feb 23, 2022
D
F-690
no actual harm; potential for more than minimal harm · isolated
Bladder and bowel care fell short — catheter care or steps to prevent urinary tract infections.
CMS requirement: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected Feb 23, 2022
D
F-692
no actual harm; potential for more than minimal harm · isolated
Residents didn't get enough food or fluids to stay healthy.
CMS requirement: Provide enough food/fluids to maintain a resident's health.
Corrected Feb 23, 2022
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 Feb 23, 2022
E
F-697
no actual harm; potential for more than minimal harm · pattern
Pain wasn't managed safely or appropriately.
CMS requirement: Provide safe, appropriate pain management for a resident who requires such services.
Corrected Feb 23, 2022
D
F-755
no actual harm; potential for more than minimal harm · isolated
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 Feb 23, 2022
F
F-756
no actual harm; potential for more than minimal harm · widespread
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 Feb 23, 2022
E
F-757
no actual harm; potential for more than minimal harm · pattern
Residents were given drugs they didn't need — excessive dose, excessive duration, or without adequate reason.
CMS requirement: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected Feb 23, 2022
D
F-761
no actual harm; potential for more than minimal harm · isolated
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 Feb 23, 2022
E
F-790
no actual harm; potential for more than minimal harm · pattern
Provide routine and 24-hour emergency dental care for each resident.
Corrected Feb 23, 2022
D
F-804
no actual harm; potential for more than minimal harm · isolated
Food served wasn't appetizing or at a safe, palatable temperature.
CMS requirement: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected Feb 23, 2022
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 Feb 23, 2022
D
F-825
no actual harm; potential for more than minimal harm · isolated
Provide or get specialized rehabilitative services as required for a resident.
Corrected Feb 23, 2022
F
F-838
no actual harm; potential for more than minimal harm · widespread
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected Feb 23, 2022
E
F-842
no actual harm; potential for more than minimal harm · pattern
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 Feb 23, 2022
F
F-880
no actual harm; potential for more than minimal harm · widespread
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 Feb 23, 2022
D
F-886
no actual harm; potential for more than minimal harm · isolated
Perform COVID19 testing on residents and staff.
Corrected Feb 23, 2022
E
F-887
no actual harm; potential for more than minimal harm · pattern
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 Feb 23, 2022
D
F-908
no actual harm; potential for more than minimal harm · isolated
Essential equipment wasn't kept in safe working order.
CMS requirement: Keep all essential equipment working safely.
Corrected Feb 23, 2022
D
F-919
no actual harm; potential for more than minimal harm · isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected Feb 23, 2022