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 Oct 21, 2022
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 Dec 2, 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 Oct 21, 2022
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 Dec 2, 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 Oct 21, 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 Oct 21, 2022
E
F-625
no actual harm; potential for more than minimal harm · pattern
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 Oct 21, 2022
D
F-635
no actual harm; potential for more than minimal harm · isolated
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected Oct 21, 2022
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 Oct 21, 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 Oct 21, 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 Oct 21, 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 Oct 21, 2022
D
F-679
no actual harm; potential for more than minimal harm · isolated
Not enough activities to meet residents' interests and needs.
CMS requirement: Provide activities to meet all resident's needs.
Corrected Oct 21, 2022
G
F-686
actual harm · isolated
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 Oct 21, 2022
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 Oct 21, 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 Dec 2, 2022
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 Dec 2, 2022
D
F-698
no actual harm; potential for more than minimal harm · isolated
Dialysis care or coordination with dialysis providers wasn't safe or appropriate.
CMS requirement: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected Oct 21, 2022
D
F-726
no actual harm; potential for more than minimal harm · isolated
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 Oct 21, 2022
D
F-744
no actual harm; potential for more than minimal harm · isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected Oct 21, 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 Dec 2, 2022
D
F-756
no actual harm; potential for more than minimal harm · isolated
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 Oct 21, 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 Oct 21, 2022
D
F-791
no actual harm; potential for more than minimal harm · isolated
Provide or obtain dental services for each resident.
Corrected Oct 21, 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 Oct 21, 2022
D
F-812
no actual harm; potential for more than minimal harm · isolated
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 Dec 2, 2022
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 Oct 21, 2022
E
F-880
no actual harm; potential for more than minimal harm · pattern
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 Oct 21, 2022
F
F-882
no actual harm; potential for more than minimal harm · widespread
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected Oct 21, 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 Oct 21, 2022
D
F-921
no actual harm; potential for more than minimal harm · isolated
Common areas weren't kept safe, clean, usable, and comfortable.
CMS requirement: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected Oct 21, 2022