Safety Report: All Saints Healthcare Subacute
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
3Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
26Requirements cited on more than one inspection
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
K
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
K
Government finding: Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Tag F759
Citations by topic
6Abuse, neglect & exploitation
10Infection control
17Medications & pharmacy
3Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (33) than in the cycle before (34).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide and implement an infection prevention and control program. (F880) | 6 | January 29, 2026; November 8, 2025; November 8, 2024; October 25, 2024; June 19, 2024; October 20, 2023 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 4 | January 29, 2026; July 17, 2025; October 25, 2024; October 20, 2023 |
| Ensure that residents are free from significant medication errors. (F760) | 4 | January 29, 2026; November 8, 2024; October 25, 2024; October 20, 2023 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 4 | January 29, 2026; November 8, 2024; October 25, 2024; October 20, 2023 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 4 | January 8, 2026; November 8, 2025; November 8, 2024; October 20, 2023 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 4 | May 15, 2025; May 2, 2025; December 12, 2024; June 19, 2024 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| 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. (F761) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Ensure medication error rates are not 5 percent or greater. (F759) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (F693) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 3 | January 29, 2026; November 8, 2025; October 25, 2024 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 3 | January 29, 2026; January 8, 2026; October 20, 2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Reasonably accommodate the needs and preferences of each resident. (F558) | 3 | January 29, 2026; October 25, 2024; October 20, 2023 |
| Implement a program that monitors antibiotic use. (F881) | 2 | January 29, 2026; October 20, 2023 |
| 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. (F726) | 2 | January 29, 2026; October 20, 2023 |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (F604) | 2 | January 29, 2026; October 25, 2024 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 2 | January 29, 2026; October 25, 2024 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580) | 2 | January 29, 2026; April 29, 2025 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | January 29, 2026; October 20, 2023 |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. (F694) | 2 | October 25, 2024; October 20, 2023 |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (F688) | 2 | October 25, 2024; October 20, 2023 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 2 | October 25, 2024; October 20, 2023 |
| 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. (F584) | 2 | October 25, 2024; October 20, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| January 29, 2026 | Fine | $35,133 |
| November 8, 2025 | Payment Denial | Payment denial for 43 days, starting December 9, 2025 |
| November 8, 2025 | Fine | $30,693 |
| October 20, 2023 | Fine | $34,112 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
January 29, 2026 — 26 citations (includes serious)
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F686 · corrected February 21, 2026
E
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F881 · corrected February 21, 2026
E
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F814 · corrected February 21, 2026
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected February 21, 2026
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected February 21, 2026
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · corrected February 21, 2026
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected February 21, 2026
E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F757 · corrected February 21, 2026
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected February 21, 2026
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected February 21, 2026
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected February 21, 2026
E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F693 · corrected February 21, 2026
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · corrected February 21, 2026
E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected February 21, 2026
D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F887 · complaint · corrected February 21, 2026
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F883 · complaint · corrected February 21, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected February 21, 2026
D
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F826 · corrected February 21, 2026
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected February 21, 2026
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected February 21, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected February 21, 2026
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected February 21, 2026
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected February 21, 2026
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected February 21, 2026
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected February 21, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected February 21, 2026
January 8, 2026 — 2 citations · complaint investigation
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 23, 2026
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected January 23, 2026
November 8, 2025 — 5 citations (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected December 22, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected January 16, 2026
E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F847 · complaint · corrected December 22, 2025
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected December 22, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F838 · complaint · corrected December 22, 2025
July 17, 2025 — 1 citation · complaint investigation
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected August 8, 2025
May 15, 2025 — 2 citations · complaint investigation
D
Provide care by qualified persons according to each resident's written plan of care.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F659 · complaint · corrected June 7, 2025
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected June 7, 2025
May 2, 2025 — 1 citation · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected May 18, 2025
April 29, 2025 — 1 citation · complaint investigation
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected May 14, 2025
December 12, 2024 — 1 citation · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected January 5, 2025
November 8, 2024 — 4 citations · complaint investigation
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected November 30, 2024
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · complaint · corrected November 30, 2024
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected November 30, 2024
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected November 30, 2024
October 25, 2024 — 24 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected November 21, 2024
E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F813 · corrected November 21, 2024
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected November 21, 2024
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected November 21, 2024
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · corrected November 21, 2024
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected November 21, 2024
E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F758 · corrected November 21, 2024
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected November 21, 2024
E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F725 · corrected November 21, 2024
E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F694 · corrected November 21, 2024
E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F693 · corrected November 21, 2024
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · corrected November 21, 2024
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected November 21, 2024
E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F688 · corrected November 21, 2024
E
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F658 · corrected November 21, 2024
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected November 21, 2024
E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected November 21, 2024
E
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F583 · corrected November 21, 2024
E
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F558 · corrected November 21, 2024
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected November 21, 2024
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected November 21, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected November 21, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected November 21, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected November 21, 2024
June 19, 2024 — 2 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected July 5, 2024
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected July 5, 2024
October 20, 2023 — 23 citations (includes serious)
K
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F760 · corrected November 13, 2023
K
Ensure medication error rates are not 5 percent or greater.
Immediate jeopardy to resident health or safety · Pattern · Pharmacy Service Deficiencies · F759 · corrected November 13, 2023
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected November 13, 2023
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected November 13, 2023
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected November 13, 2023
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected November 13, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected November 13, 2023
E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F700 · corrected November 13, 2023
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected November 13, 2023
E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F693 · corrected November 13, 2023
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · corrected November 13, 2023
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected November 13, 2023
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected November 13, 2023
E
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F658 · corrected November 13, 2023
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected November 13, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected November 13, 2023
E
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F558 · corrected November 13, 2023
D
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F881 · corrected November 13, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected November 13, 2023
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected November 13, 2023
D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F694 · corrected November 13, 2023
D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected November 13, 2023
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected November 13, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare