Safety Report: Aria of Brookfield
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)
7Actual harm citations (severity G–I)
24Requirements 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
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
J
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
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
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F692
Citations by topic
7Abuse, neglect & exploitation
7Infection control
15Medications & pharmacy
7Accidents & 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 (31) than in the cycle before (51).
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 |
|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 7 | January 29, 2025; December 11, 2024; November 5, 2024; September 9, 2024; July 16, 2024; May 22, 2024; March 5, 2024 |
| Provide and implement an infection prevention and control program. (F880) | 6 | July 22, 2026; August 27, 2025; January 29, 2025; July 16, 2024; May 22, 2024; October 16, 2023 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 6 | January 8, 2026; August 27, 2025; November 5, 2024; July 16, 2024; May 22, 2024; October 16, 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) | 6 | December 11, 2024; July 16, 2024; May 22, 2024; January 5, 2024; October 16, 2023; May 11, 2023 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 5 | July 22, 2026; August 27, 2025; May 8, 2025; January 29, 2025; October 16, 2023 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 5 | January 8, 2026; November 5, 2024; July 16, 2024; May 22, 2024; January 5, 2024 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 5 | January 29, 2025; December 11, 2024; May 22, 2024; October 16, 2023; May 11, 2023 |
| 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) | 4 | February 5, 2026; July 16, 2024; May 22, 2024; May 11, 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) | 4 | January 8, 2026; August 27, 2025; May 8, 2025; May 22, 2024 |
| Ensure that residents are free from significant medication errors. (F760) | 3 | July 22, 2026; November 5, 2024; October 16, 2023 |
| Allow residents to self-administer drugs if determined clinically appropriate. (F554) | 3 | July 22, 2026; July 16, 2024; February 9, 2024 |
| Provide enough food/fluids to maintain a resident's health. (F692) | 3 | January 8, 2026; October 16, 2023; May 11, 2023 |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (F849) | 3 | August 27, 2025; November 5, 2024; May 22, 2024 |
| 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 | August 27, 2025; May 22, 2024; May 11, 2023 |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. (F628) | 2 | July 22, 2026; August 27, 2025 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. (F698) | 2 | January 8, 2026; October 16, 2023 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | January 8, 2026; August 27, 2025 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | August 27, 2025; May 22, 2024 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | August 27, 2025; December 11, 2024 |
| Ensure that residents are fully informed and understand their health status, care and treatments. (F552) | 2 | August 27, 2025; January 29, 2025 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | June 10, 2025; January 29, 2025 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (F725) | 2 | January 29, 2025; May 22, 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 | September 9, 2024; October 16, 2023 |
| Keep residents' personal and medical records private and confidential. (F583) | 2 | July 16, 2024; October 16, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| August 27, 2025 | Fine | $49,920 |
| November 5, 2024 | Payment Denial | Payment denial for 72 days, starting December 4, 2024 |
| November 5, 2024 | Fine | $184,725 |
| May 22, 2024 | Payment Denial | Payment denial for 35 days, starting June 27, 2024 |
| May 22, 2024 | Fine | $132,997 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
July 22, 2026 — 8 citations · complaint investigation
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 · complaint · corrected August 14, 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 · complaint · corrected August 14, 2026
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 August 14, 2026
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 August 14, 2026
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 August 14, 2026
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 · complaint · corrected August 14, 2026
D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F620 · complaint · corrected August 14, 2026
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · complaint · corrected August 14, 2026
February 5, 2026 — 1 citation · complaint investigation
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 · complaint · corrected February 16, 2026
January 8, 2026 — 8 citations · complaint investigation
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 · complaint · corrected February 2, 2026
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · complaint · corrected February 2, 2026
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 · complaint · corrected February 2, 2026
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 February 2, 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 · complaint · corrected February 2, 2026
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 February 2, 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 · complaint · corrected February 2, 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 · complaint · corrected February 2, 2026
August 27, 2025 — 14 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 · complaint · corrected September 16, 2025
F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F851 · corrected September 16, 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 · corrected September 16, 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 · corrected September 16, 2025
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 September 16, 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 · corrected September 16, 2025
E
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 · Pattern · Resident Rights Deficiencies · F628 · corrected September 16, 2025
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · corrected September 16, 2025
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected September 16, 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 September 16, 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 September 16, 2025
D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected September 16, 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 · corrected September 16, 2025
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 September 16, 2025
June 10, 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 June 25, 2025
May 8, 2025 — 4 citations · complaint investigation
F
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F908 · complaint · corrected June 2, 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 2, 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 2, 2025
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 · complaint · corrected June 2, 2025
January 29, 2025 — 12 citations · complaint investigation
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 · complaint · corrected February 14, 2025
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 February 14, 2025
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · complaint · corrected February 14, 2025
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 February 14, 2025
D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · complaint · corrected February 14, 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 · complaint · corrected February 14, 2025
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 · complaint · corrected February 14, 2025
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 February 14, 2025
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected February 14, 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 February 14, 2025
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 · complaint · corrected February 14, 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 February 14, 2025
December 11, 2024 — 5 citations (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 February 14, 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 · complaint · corrected January 6, 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 · complaint · corrected January 6, 2025
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 · complaint · corrected February 14, 2025
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · complaint · corrected January 6, 2025
November 5, 2024 — 7 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 February 14, 2025
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected November 25, 2024
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 · corrected November 25, 2024
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · complaint · corrected November 25, 2024
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 November 25, 2024
D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F745 · complaint · corrected November 25, 2024
D
Provide appropriate foot care.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F687 · complaint · corrected November 25, 2024
September 9, 2024 — 2 citations · complaint investigation
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 · complaint · corrected September 26, 2024
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 September 26, 2024
July 16, 2024 — 10 citations · complaint investigation
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 August 1, 2024
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 August 1, 2024
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 August 1, 2024
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 · complaint · corrected August 1, 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 · complaint · corrected August 1, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · complaint · corrected August 1, 2024
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · complaint · corrected August 1, 2024
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 · complaint · corrected August 1, 2024
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 · complaint · corrected August 1, 2024
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · complaint · corrected August 1, 2024
May 22, 2024 — 22 citations (includes serious)
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 1, 2024
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 · complaint · corrected August 1, 2024
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 · corrected August 1, 2024
F
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F881 · corrected June 25, 2024
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 August 1, 2024
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 · complaint · corrected June 25, 2024
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 June 25, 2024
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 · corrected June 25, 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 June 25, 2024
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected June 25, 2024
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 August 1, 2024
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · corrected June 25, 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 June 25, 2024
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 June 25, 2024
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 June 25, 2024
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 · complaint · corrected June 25, 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 · complaint · corrected June 25, 2024
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 · complaint · corrected June 25, 2024
D
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 · Isolated · Resident Rights Deficiencies · F622 · complaint · corrected June 25, 2024
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 · complaint · corrected August 1, 2024
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 June 25, 2024
D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · corrected June 25, 2024
March 5, 2024 — 1 citation · complaint investigation
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 · complaint · corrected March 28, 2024
February 9, 2024 — 1 citation · complaint investigation
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · complaint · corrected March 9, 2024
January 5, 2024 — 3 citations · complaint investigation
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 February 5, 2024
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 · complaint · corrected February 5, 2024
C
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, potential for minimal harm · Widespread · Resident Rights Deficiencies · F584 · complaint · corrected February 5, 2024
October 16, 2023 — 12 citations (includes serious) · complaint investigation
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected November 8, 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 · complaint · corrected November 8, 2023
F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F727 · complaint · corrected November 8, 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 · complaint · corrected November 8, 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 · complaint · corrected November 8, 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 · complaint · corrected November 8, 2023
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 November 8, 2023
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · complaint · corrected November 8, 2023
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 · complaint · corrected November 8, 2023
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 · complaint · corrected November 8, 2023
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 · complaint · corrected November 8, 2023
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 8, 2023
May 11, 2023 — 6 citations
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 · corrected June 7, 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 June 7, 2023
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 June 7, 2023
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 June 7, 2023
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 June 7, 2023
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 June 7, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare