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 Jan 9, 2023
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 Jan 9, 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 Jan 9, 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 Feb 8, 2023
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 Jan 9, 2023
E
F-641
no actual harm; potential for more than minimal harm · pattern
Resident health assessments were inaccurate.
CMS requirement: Ensure each resident receives an accurate assessment.
Corrected Jan 9, 2023
F
F-656
no actual harm; potential for more than minimal harm · widespread
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 Jan 9, 2023
E
F-657
no actual harm; potential for more than minimal harm · pattern
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 8, 2023
D
F-658
no actual harm; potential for more than minimal harm · isolated
Care provided didn't meet professional standards of quality.
CMS requirement: Ensure services provided by the nursing facility meet professional standards of quality.
Corrected Jan 9, 2023
G
F-684
actual harm · isolated
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 9, 2023
D
F-686
no actual harm; potential for more than minimal 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 Jan 9, 2023
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 Jan 9, 2023
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 Jan 9, 2023
D
F-711
no actual harm; potential for more than minimal harm · isolated
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected Jan 9, 2023
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 Jan 9, 2023
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 9, 2023
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 Feb 8, 2023
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 Jan 9, 2023
D
F-773
no actual harm; potential for more than minimal harm · isolated
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected Jan 9, 2023
D
F-776
no actual harm; potential for more than minimal harm · isolated
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected Jan 9, 2023
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 Jan 9, 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 Feb 8, 2023
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 Feb 8, 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 Jan 9, 2023