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 Mar 10, 2023
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 Mar 10, 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 Mar 10, 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 Mar 10, 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 Mar 10, 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 Mar 10, 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 Mar 10, 2023
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 Mar 10, 2023
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 Mar 10, 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 Mar 10, 2023
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 Mar 10, 2023
D
F-925
no actual harm; potential for more than minimal harm · isolated
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected Mar 10, 2023