D
F-867
no actual harm; potential for more than minimal harm · isolated
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected Oct 25, 2024
D
F-550
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
E
F-569
no actual harm; potential for more than minimal harm · pattern · found via complaint
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected Aug 31, 2024
D
F-604
no actual harm; potential for more than minimal harm · isolated · found via complaint
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected Aug 31, 2024
D
F-607
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
D
F-609
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
D
F-610
no actual harm; potential for more than minimal harm · isolated · found via complaint
Reported abuse or neglect allegations weren't properly investigated or acted on.
CMS requirement: Respond appropriately to all alleged violations.
Corrected Aug 31, 2024
D
F-623
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
E
F-641
no actual harm; potential for more than minimal harm · pattern · found via complaint
Resident health assessments were inaccurate.
CMS requirement: Ensure each resident receives an accurate assessment.
Corrected Aug 31, 2024
D
F-655
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 25, 2024
E
F-656
no actual harm; potential for more than minimal harm · pattern · found via complaint
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 25, 2024
D
F-657
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
D
F-677
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
D
F-684
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
D
F-685
no actual harm; potential for more than minimal harm · isolated · found via complaint
Assist a resident in gaining access to vision and hearing services.
Corrected Aug 31, 2024
J
F-689
immediate jeopardy to resident health or safety · isolated · found via complaint
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 Aug 31, 2024
D
F-695
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
D
F-812
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024
C
F-838
no actual harm; minimal potential · widespread · found via complaint
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 Aug 31, 2024
D
F-908
no actual harm; potential for more than minimal harm · isolated · found via complaint
Essential equipment wasn't kept in safe working order.
CMS requirement: Keep all essential equipment working safely.
Corrected Aug 31, 2024
D
F-921
no actual harm; potential for more than minimal harm · isolated · found via complaint
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 Aug 31, 2024