CMS · Agency for Health Care Administration (AHCA) publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-13Record 105394-20260413-F584
F585Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-13Record 105394-20260413-F585
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-13Record 105394-20260413-F677
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-13Record 105394-20260413-F695
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-13Record 105394-20260413-F726
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-23Record 105394-20260223-F580
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-23Record 105394-20260223-F688
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-12-19Record 105394-20251120-F600
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-12-19Record 105394-20251120-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-12-19Record 105394-20251120-F692
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity JHarm
Staffing
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-12-19Record 105394-20251120-F726
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F561
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F578
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F584
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F645
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F660
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F684
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F756
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-09Record 105394-20240809-F801
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F623
F625Notify 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F625
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F657
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F685
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F686
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F693
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F745
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-07-19Record 105394-20220422-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-07-19Record 105394-20220422-F759
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-05-19Record 105394-20220422-F761
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-07-19Record 105394-20220422-F867
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F554
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F578
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F689
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F812
F840Employ 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.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F840
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-18Record 105394-20210218-F883