Safety Report: Pines Nursing and Rehab
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
2Immediate jeopardy citations (severity J–L)
4Actual harm citations (severity G–I)
47Requirements cited on more than one inspection
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
G
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
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
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
K
Government finding: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Quality of Life and Care Deficiencies · Tag F678
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F692
Citations by topic
9Abuse, neglect & exploitation
8Infection control
14Medications & pharmacy
4Accidents & 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 (53) than in the cycle before (102).
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 appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 5 | August 19, 2026; September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Keep all essential equipment working safely. (F908) | 5 | March 12, 2026; September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 5 | March 12, 2026; September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| 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) | 5 | March 12, 2026; September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 5 | March 12, 2026; September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580) | 5 | March 12, 2026; September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 4 | July 2, 2026; September 4, 2025; March 19, 2025; September 28, 2022 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 4 | March 12, 2026; September 4, 2025; March 19, 2025; September 28, 2022 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 4 | March 12, 2026; September 4, 2025; September 28, 2022; October 25, 2018 |
| Ensure each resident receives an accurate assessment. (F641) | 4 | March 12, 2026; September 4, 2025; March 19, 2025; October 25, 2018 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 4 | September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Make sure that a working call system is available in each resident's bathroom and bathing area. (F919) | 4 | September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 4 | September 4, 2025; March 19, 2025; September 28, 2022; October 25, 2018 |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (F925) | 3 | March 12, 2026; September 4, 2025; March 19, 2025 |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (F921) | 3 | March 12, 2026; September 4, 2025; September 28, 2022 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 3 | March 12, 2026; September 4, 2025; September 28, 2022 |
| Provide and implement an infection prevention and control program. (F880) | 3 | September 4, 2025; September 28, 2022; October 25, 2018 |
| 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. (F578) | 3 | September 4, 2025; September 28, 2022; October 25, 2018 |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (F947) | 3 | September 4, 2025; March 19, 2025; September 28, 2022 |
| 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 | September 4, 2025; March 19, 2025; September 28, 2022 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F756) | 3 | September 4, 2025; September 28, 2022; October 25, 2018 |
| Post nurse staffing information every day. (F732) | 3 | September 4, 2025; March 19, 2025; September 28, 2022 |
| Honor the resident's right to organize and participate in resident/family groups in the facility. (F565) | 3 | September 4, 2025; September 28, 2022; October 25, 2018 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (F725) | 3 | March 19, 2025; September 28, 2022; October 25, 2018 |
| Provide enough food/fluids to maintain a resident's health. (F692) | 3 | March 19, 2025; September 28, 2022; October 25, 2018 |
| Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. (F809) | 3 | March 19, 2025; September 28, 2022; October 25, 2018 |
| Ensure each resident’s drug regimen must be free from unnecessary drugs. (F757) | 3 | March 19, 2025; September 28, 2022; October 25, 2018 |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (F585) | 2 | August 19, 2026; September 4, 2025 |
| Respond appropriately to all alleged violations. (F610) | 2 | September 4, 2025; March 19, 2025 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | September 4, 2025; March 19, 2025 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. (F883) | 2 | September 4, 2025; September 28, 2022 |
| Provide routine and 24-hour emergency dental care for each resident. (F790) | 2 | September 4, 2025; September 28, 2022 |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (F636) | 2 | September 4, 2025; September 28, 2022 |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (F561) | 2 | September 4, 2025; October 25, 2018 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 2 | March 19, 2025; October 25, 2018 |
| Hire a qualified full-time social worker in a facility with more than 120 beds. (F850) | 2 | March 19, 2025; September 28, 2022 |
| Observe each nurse aide's job performance and give regular training. (F730) | 2 | March 19, 2025; September 28, 2022 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (F804) | 2 | March 19, 2025; September 28, 2022 |
| Ensure that residents are free from significant medication errors. (F760) | 2 | March 19, 2025; September 28, 2022 |
| 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. (F758) | 2 | March 19, 2025; October 25, 2018 |
| 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 | March 19, 2025; September 28, 2022 |
| Assure that each resident’s assessment is updated at least once every 3 months. (F638) | 2 | March 19, 2025; September 28, 2022 |
| Protect each resident from the wrongful use of the resident's belongings or money. (F602) | 2 | March 19, 2025; September 28, 2022 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (F655) | 2 | September 28, 2022; October 25, 2018 |
| Provide safe, appropriate pain management for a resident who requires such services. (F697) | 2 | September 28, 2022; October 25, 2018 |
| 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. (F625) | 2 | September 28, 2022; October 25, 2018 |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (F623) | 2 | September 28, 2022; October 25, 2018 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| July 2, 2026 | Fine | $27,378 |
| July 2, 2026 | Fine | $19,635 |
| March 19, 2025 | Fine | $24,088 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 19, 2026 — 3 citations (includes serious) · complaint investigation
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · complaint
E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F940 · complaint
E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F585 · complaint
July 2, 2026 — 1 citation (includes serious) · complaint investigation
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected August 17, 2026
March 12, 2026 — 12 citations · complaint investigation
E
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · complaint · corrected April 28, 2026
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 · complaint · corrected April 28, 2026
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 · complaint · corrected April 28, 2026
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 · complaint · corrected April 28, 2026
E
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 · Pattern · Resident Rights Deficiencies · F550 · complaint · corrected April 28, 2026
D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F925 · complaint · corrected April 28, 2026
D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F921 · complaint · corrected April 28, 2026
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 · complaint · corrected April 28, 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 · complaint · corrected April 28, 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 · complaint · corrected April 28, 2026
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected April 28, 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 · complaint · corrected April 28, 2026
September 4, 2025 — 38 citations
F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F925 · corrected November 10, 2025
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected November 10, 2025
F
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 · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected November 10, 2025
E
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F919 · complaint · corrected November 10, 2025
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 10, 2025
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected November 10, 2025
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 10, 2025
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected November 10, 2025
E
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 · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected November 10, 2025
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 10, 2025
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F578 · corrected November 10, 2025
E
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 · Pattern · Resident Rights Deficiencies · F550 · corrected November 10, 2025
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 November 10, 2025
D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F947 · corrected November 10, 2025
D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F921 · corrected November 10, 2025
D
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F908 · complaint · corrected November 10, 2025
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 · corrected November 10, 2025
D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F868 · corrected November 10, 2025
D
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F807 · corrected November 10, 2025
D
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F790 · corrected November 10, 2025
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 10, 2025
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 10, 2025
D
Post nurse staffing information every day.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F732 · corrected November 10, 2025
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 10, 2025
D
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 · Isolated · Quality of Life and Care Deficiencies · F693 · corrected November 10, 2025
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 November 10, 2025
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 · complaint · corrected November 10, 2025
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 November 10, 2025
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected November 10, 2025
D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F640 · corrected November 10, 2025
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F636 · corrected November 10, 2025
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F628 · corrected November 10, 2025
D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · corrected November 10, 2025
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected November 10, 2025
D
Give residents a notice of rights, rules, services and charges.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F572 · corrected November 10, 2025
D
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F565 · corrected November 10, 2025
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · corrected November 10, 2025
D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F553 · corrected November 10, 2025
March 19, 2025 — 37 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 May 27, 2025
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected May 27, 2025
F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F947 · complaint · corrected June 20, 2025
F
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F908 · complaint · corrected June 20, 2025
F
Hire a qualified full-time social worker in a facility with more than 120 beds.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F850 · complaint · corrected May 27, 2025
F
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F730 · complaint · corrected May 27, 2025
F
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 · Widespread · Nursing and Physician Services Deficiencies · F725 · complaint · corrected May 27, 2025
F
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 · Widespread · Resident Rights Deficiencies · F584 · complaint · corrected June 20, 2025
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F925 · complaint · corrected June 20, 2025
E
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F919 · complaint · corrected June 20, 2025
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 · complaint · corrected June 20, 2025
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 · complaint · corrected June 20, 2025
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · complaint · corrected June 20, 2025
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 · complaint · corrected June 20, 2025
E
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F692 · complaint · corrected May 27, 2025
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 June 20, 2025
E
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 · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected June 20, 2025
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected May 27, 2025
E
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 · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected May 27, 2025
E
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 · Pattern · Resident Rights Deficiencies · F550 · complaint · corrected June 20, 2025
D
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F840 · complaint · corrected May 27, 2025
D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F809 · complaint · corrected May 27, 2025
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 · complaint · corrected June 16, 2025
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected May 27, 2025
D
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 · Isolated · Pharmacy Service Deficiencies · F758 · complaint · corrected May 27, 2025
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · complaint · corrected June 20, 2025
D
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 · Isolated · Quality of Life and Care Deficiencies · F690 · complaint · corrected May 27, 2025
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 · complaint · corrected May 27, 2025
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 · complaint · corrected May 27, 2025
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected May 27, 2025
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 · complaint · corrected May 27, 2025
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected June 20, 2025
D
Assure that each resident’s assessment is updated at least once every 3 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F638 · complaint · corrected May 27, 2025
D
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · complaint · corrected May 27, 2025
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 27, 2025
D
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F552 · complaint · corrected May 27, 2025
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · complaint · corrected May 27, 2025
September 28, 2022 — 64 citations (includes serious)
K
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F678 · corrected March 18, 2023
G
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F692 · corrected November 27, 2022
F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F947 · corrected March 3, 2023
F
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · corrected November 27, 2022
F
Perform COVID19 testing on residents and staff.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F886 · corrected November 27, 2022
F
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F881 · corrected November 27, 2022
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected March 3, 2023
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected March 3, 2023
F
Hire a qualified full-time social worker in a facility with more than 120 beds.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F850 · corrected March 3, 2023
F
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 · Widespread · Administration Deficiencies · F838 · corrected March 3, 2023
F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F835 · corrected March 3, 2023
F
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 · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected November 27, 2022
F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F804 · corrected November 27, 2022
F
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 · Widespread · Pharmacy Service Deficiencies · F761 · corrected March 3, 2023
F
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
No actual harm, but potential for more than minimal harm · Widespread · Quality of Life and Care Deficiencies · F741 · corrected March 3, 2023
F
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F730 · corrected March 3, 2023
F
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 · Widespread · Nursing and Physician Services Deficiencies · F726 · corrected March 3, 2023
F
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 · Widespread · Nursing and Physician Services Deficiencies · F725 · corrected November 27, 2022
F
Ensure the activities program is directed by a qualified professional.
No actual harm, but potential for more than minimal harm · Widespread · Quality of Life and Care Deficiencies · F680 · corrected March 3, 2023
F
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Widespread · Quality of Life and Care Deficiencies · F679 · corrected March 3, 2023
F
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 · Widespread · Resident Assessment and Care Planning Deficiencies · F656 · corrected March 3, 2023
F
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 · Widespread · Resident Rights Deficiencies · F584 · corrected March 18, 2023
F
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Widespread · Resident Rights Deficiencies · F565 · corrected November 27, 2022
E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F921 · corrected November 27, 2022
E
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F919 · corrected March 3, 2023
E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F909 · corrected November 27, 2022
E
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · corrected March 3, 2023
E
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 · Pattern · Infection Control Deficiencies · F887 · corrected November 27, 2022
E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F883 · corrected March 3, 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 March 18, 2023
E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F809 · corrected March 3, 2023
E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F805 · corrected November 27, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F803 · corrected November 27, 2022
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 March 3, 2023
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 March 18, 2023
E
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 · Pattern · Pharmacy Service Deficiencies · F756 · corrected March 3, 2023
E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F712 · corrected November 27, 2022
E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F711 · corrected March 3, 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 March 3, 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 March 3, 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 · corrected November 27, 2022
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 March 18, 2023
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected March 3, 2023
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F655 · corrected March 3, 2023
E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F636 · corrected March 3, 2023
E
Prepare residents for a safe transfer or discharge from the nursing home.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F624 · corrected March 3, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F622 · corrected November 27, 2022
E
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 · Pattern · Resident Rights Deficiencies · F580 · corrected March 3, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F578 · corrected November 27, 2022
E
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 · Pattern · Resident Rights Deficiencies · F550 · corrected November 27, 2022
D
Provide or get specialized rehabilitative services as required for a resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F825 · corrected November 27, 2022
D
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F790 · corrected November 27, 2022
D
Keep complete, dated laboratory records in the resident's record.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F775 · corrected November 27, 2022
D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F710 · corrected November 27, 2022
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected November 27, 2022
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 March 3, 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 27, 2022
D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F661 · corrected March 3, 2023
D
Assure that each resident’s assessment is updated at least once every 3 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F638 · corrected November 27, 2022
D
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · corrected November 27, 2022
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · corrected November 27, 2022
C
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.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F625 · corrected November 27, 2022
C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F623 · corrected March 3, 2023
C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F577 · corrected March 3, 2023
October 25, 2018 — 28 citations
E
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · corrected December 1, 2018
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 December 1, 2018
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 December 1, 2018
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 December 1, 2018
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected December 1, 2018
E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F623 · corrected December 1, 2018
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 December 1, 2018
E
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F565 · corrected December 1, 2018
D
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F919 · corrected December 1, 2018
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 December 1, 2018
D
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F809 · corrected December 1, 2018
D
Provide or obtain dental services for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F791 · corrected December 1, 2018
D
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 · Isolated · Pharmacy Service Deficiencies · F758 · corrected December 1, 2018
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected December 1, 2018
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 December 1, 2018
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected December 1, 2018
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected December 1, 2018
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 December 1, 2018
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 December 1, 2018
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 December 1, 2018
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 December 1, 2018
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected December 1, 2018
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · corrected December 1, 2018
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected May 10, 2018
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 December 1, 2018
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected December 1, 2018
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · corrected December 1, 2018
D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F559 · corrected December 1, 2018
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare