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 Dec 8, 2021
E
F-578
no actual harm; potential for more than minimal harm · pattern
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 Nov 2, 2021
D
F-584
no actual harm; potential for more than minimal harm · isolated
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 Dec 8, 2021
K
F-600
immediate jeopardy to resident health or safety · pattern
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 Nov 2, 2021
D
F-604
no actual harm; potential for more than minimal harm · isolated
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected Nov 2, 2021
F
F-610
no actual harm; potential for more than minimal harm · widespread
Reported abuse or neglect allegations weren't properly investigated or acted on.
CMS requirement: Respond appropriately to all alleged violations.
Corrected Dec 8, 2021
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 Nov 2, 2021
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 Nov 2, 2021
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 Nov 2, 2021
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 Dec 8, 2021
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 Nov 2, 2021
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 Nov 2, 2021
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 Jan 10, 2022
K
F-686
immediate jeopardy to resident health or safety · 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 Dec 8, 2021
D
F-688
no actual harm; potential for more than minimal harm · isolated
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 Nov 2, 2021
D
F-689
no actual harm; potential for more than minimal harm · isolated
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 Nov 2, 2021
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 Nov 2, 2021
E
F-695
no actual harm; potential for more than minimal harm · pattern
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 Nov 2, 2021
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 Dec 8, 2021
F
F-725
no actual harm; potential for more than minimal harm · widespread
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 Nov 2, 2021
E
F-726
no actual harm; potential for more than minimal harm · pattern
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 Jan 10, 2022
D
F-732
no actual harm; potential for more than minimal harm · isolated
Daily nurse staffing numbers weren't posted for the public.
CMS requirement: Post nurse staffing information every day.
Corrected Nov 2, 2021
D
F-740
no actual harm; potential for more than minimal harm · isolated
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected Nov 2, 2021
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 Jan 10, 2022
D
F-757
no actual harm; potential for more than minimal harm · isolated
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 Nov 2, 2021
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 Dec 8, 2021
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 Nov 2, 2021
F
F-835
no actual harm; potential for more than minimal harm · widespread
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected Nov 2, 2021
F
F-837
no actual harm; potential for more than minimal harm · widespread
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected Nov 2, 2021
C
F-838
no actual harm; minimal potential · 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 Nov 2, 2021
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 Jan 10, 2022
F
F-867
no actual harm; potential for more than minimal harm · widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected Jan 10, 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 Dec 8, 2021
E
F-883
no actual harm; potential for more than minimal harm · pattern
Flu and pneumonia vaccination policies were missing or not followed.
CMS requirement: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected Nov 2, 2021
E
F-908
no actual harm; potential for more than minimal harm · pattern
Essential equipment wasn't kept in safe working order.
CMS requirement: Keep all essential equipment working safely.
Corrected Dec 8, 2021
E
F-943
no actual harm; potential for more than minimal harm · pattern
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected Nov 2, 2021
E
F-947
no actual harm; potential for more than minimal harm · pattern
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected Nov 2, 2021