The Pavilion at Sunny Hills

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0552. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0552 2 times since 2023.

• Citation F0578. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0578 3 times since 2023.

• Citation F0605. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on August 2, 2026.

• Citation F0628. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on August 2, 2026.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0684 6 times since 2023.

• Citation F0693. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0693 2 times since 2023.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0695 4 times since 2023.

• Citation F0698. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0698 2 times since 2023.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0761 3 times since 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0812 3 times since 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0880 4 times since 2023.

• Citation F0908. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0908 3 times since 2023.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0554 3 times since 2023.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on August 2, 2026.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0656 4 times since 2023.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0657 3 times since 2023.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on August 2, 2026.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on August 2, 2026.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0692 3 times since 2025.

• Citation F0694. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0694 3 times since 2023.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0697 2 times since 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0755 4 times since 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0757 2 times since 2025.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on August 2, 2026.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0803 2 times since 2025.

• Citation F0838. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 2, 2026.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on August 2, 2026.

  CMS has cited this home for F0842 3 times since 2025.

• Citation F0849. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 2, 2026.

• Citation F0655. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on August 2, 2026.

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CMS lists this as a standard inspection.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on July 18, 2026.

• Citation K0351. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on July 18, 2026.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on July 18, 2026.

  CMS has cited this home for K0511 2 times since 2023.

• Citation E0030. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on July 18, 2026.

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• Ownership

  CMS lists this home under a new chain.

CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on June 19, 2026.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on June 19, 2026.

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CMS lists this as a complaint inspection.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on April 16, 2026.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on April 16, 2026.

  CMS has cited this home for F0690 2 times since 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on April 16, 2026.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0656. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on March 16, 2026.

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CMS lists this as a complaint inspection.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on February 13, 2026.

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CMS lists this as a complaint inspection.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on December 25, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 25, 2025.

  CMS has cited this home for F0689 3 times since 2023.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on July 23, 2025.

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CMS lists this as a complaint inspection.

• Citation F0842. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on June 16, 2025.

See this home on CMS Care Compare

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 28, 2025.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on May 28, 2025.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 28, 2025.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on May 28, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on May 28, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on May 28, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 28, 2025.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on May 28, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on May 28, 2025.

• Citation F0694. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  CMS lists it as corrected on May 28, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on May 28, 2025.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on May 28, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on May 28, 2025.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on May 28, 2025.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 28, 2025.

  CMS has cited this home for F0758 2 times since 2023.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 28, 2025.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 28, 2025.

• Citation F0813. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a policy regarding use and storage of foods brought to residents by family and other visitors.

  CMS lists it as corrected on May 28, 2025.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on May 28, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 28, 2025.

• Citation F0908. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on May 28, 2025.

• Citation F0554. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on May 28, 2025.

• Citation F0583. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on May 28, 2025.

  CMS has cited this home for F0583 2 times since 2023.

• Citation F0641. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on May 28, 2025.

• Citation F0814. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on May 28, 2025.

  CMS has cited this home for F0814 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on May 7, 2025.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on May 7, 2025.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on May 7, 2025.

  CMS has cited this home for K0923 2 times since 2023.

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CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on April 17, 2025.

• Citation F0836. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

  CMS lists it as corrected on April 17, 2025.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on August 30, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on June 28, 2024.

See this home on CMS Care Compare

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on January 7, 2024.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 7, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on January 7, 2024.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on January 7, 2024.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 7, 2024.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 7, 2024.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on January 7, 2024.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on January 7, 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 7, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on January 7, 2024.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 7, 2024.

• Citation F0694. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  CMS lists it as corrected on January 7, 2024.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on January 7, 2024.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on January 7, 2024.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on January 7, 2024.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 7, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 7, 2024.

• Citation F0881. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on January 7, 2024.

• Citation F0909. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 7, 2024.

• Citation F0552. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on January 7, 2024.

• Citation F0583. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on January 7, 2024.

• Citation F0657. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on January 7, 2024.

• Citation F0814. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on January 7, 2024.

• Citation F0908. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on January 7, 2024.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

• Citation E0009. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on January 8, 2024.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on January 8, 2024.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on January 8, 2024.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on January 8, 2024.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on January 8, 2024.

• Citation K0711. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on January 8, 2024.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on January 8, 2024.

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CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on December 8, 2023.

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