CMS · Maryland Office of Health Care Quality 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.
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 2019-06-12Record 215272-20190429-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 2019-06-12Record 215272-20190429-F578
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 2019-06-12Record 215272-20190429-F580
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-06-12Record 215272-20190429-F656
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 EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-06-12Record 215272-20190429-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-06-12Record 215272-20190429-F658
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 2019-06-12Record 215272-20190429-F684
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 2019-06-12Record 215272-20190429-F685
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 2019-06-12Record 215272-20190429-F689
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-06-12Record 215272-20190429-F697
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 2019-06-12Record 215272-20190429-F758
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-06-12Record 215272-20190429-F842
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-06-12Record 215272-20190429-F867
F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Scope/severity BPaperwork
Staffing
Pattern; potential for minimal harm.Corrected 2019-06-12Record 215272-20190429-F712
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 BPaperwork
Medication
Pattern; potential for minimal harm.Corrected 2019-06-12Record 215272-20190429-F761
F850Hire a qualified full-time social worker in a facility with more than 120 beds.Scope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2019-06-12Record 215272-20190429-F850
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 2018-06-08Record 215272-20180430-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 2018-06-08Record 215272-20180430-F684
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2018-06-08Record 215272-20180430-F697
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 EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2018-06-08Record 215272-20180430-F756
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 EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2018-06-08Record 215272-20180430-F758
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2018-06-08Record 215272-20180430-F867
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2018-06-08Record 215272-20180430-F880
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 BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F578
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F582
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-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 BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F625
F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F640
F641Ensure each resident receives an accurate assessment.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F655
F730Observe each nurse aide's job performance and give regular training.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F730
F838Conduct 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.Scope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F838
F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F841
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyScope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F868
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2018-06-08Record 215272-20180430-F947