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
D
F-582
no actual harm; potential for more than minimal harm · isolated
Residents weren't told what Medicare/Medicaid covers and what they could be billed for.
CMS requirement: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected Dec 5, 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 Dec 5, 2022
G
F-600
actual 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 Dec 5, 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 Dec 5, 2022
D
F-608
no actual harm; potential for more than minimal harm · isolated
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected Dec 5, 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 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 Jan 9, 2023
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 Dec 5, 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 Jan 9, 2023
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 Dec 5, 2022
D
F-636
no actual harm; potential for more than minimal harm · isolated
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected Dec 5, 2022
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 Dec 5, 2022
D
F-642
no actual harm; potential for more than minimal harm · isolated
Ensure a qualified health professional conducts resident assessments.
Corrected Dec 5, 2022
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 Dec 5, 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 Dec 5, 2022
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 Dec 5, 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 Dec 5, 2022
D
F-684
no actual harm; potential for more than minimal 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-685
no actual harm; potential for more than minimal harm · isolated
Assist a resident in gaining access to vision and hearing services.
Corrected Dec 5, 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 Dec 5, 2022
G
F-689
actual 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-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 5, 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 Dec 5, 2022
E
F-755
no actual harm; potential for more than minimal harm · pattern
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 27, 2023
E
F-770
no actual harm; potential for more than minimal harm · pattern
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected Jan 9, 2023
D
F-803
no actual harm; potential for more than minimal harm · isolated
Menus didn't meet residents' nutritional needs or weren't followed.
CMS requirement: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected Dec 5, 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 Dec 5, 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 Jan 9, 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 Dec 5, 2022
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 5, 2022