Thornton Care Center

• Star rating

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

• Star rating

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

CMS lists this as a complaint inspection.

• 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 September 16, 2026.

  CMS has cited this home for F0689 5 times since 2022.

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• Star rating

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

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

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

• Star rating

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

• Ownership

  CMS lists this home under a new chain.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS no longer lists a chain for this home.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

53 of 210 Colorado homes (25%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual 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 September 3, 2025.

• Citation F0585. Severity E: potential for more than minimal harm, pattern.

  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 September 3, 2025.

  CMS has cited this home for F0585 2 times since 2022.

• 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 September 3, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 5 of 5.

• Health citation

  CMS removed citation F0622 from the health inspection on December 19, 2024.

• Health citation

  CMS removed citation F0626 from the health inspection on December 19, 2024.

• Name

  CMS lists a new legal business name for this home.

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 April 16, 2025.

  CMS has cited this home for F0600 4 times since 2022.

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• Health citation

  CMS removed citation F0661 from the health inspection on December 19, 2024.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Staffing

  Total nurse staffing reported to CMS went from 3.5 to 3.0 hours per resident per day.

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

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  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 13, 2025.

  CMS has cited this home for F0812 2 times since 2023.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on January 13, 2025.

  CMS has cited this home for F0867 3 times since 2022.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on January 13, 2025.

  CMS has cited this home for F0880 2 times since 2022.

• Citation F0561. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS lists it as corrected on January 13, 2025.

• Citation F0567. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to manage his or her financial affairs.

  CMS lists it as corrected on January 13, 2025.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 13, 2025.

  CMS has cited this home for F0584 2 times since 2022.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  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 13, 2025.

• 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 13, 2025.

  CMS has cited this home for F0761 3 times since 2022.

• Citation F0800. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

  CMS lists it as corrected on January 13, 2025.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on January 13, 2025.

  CMS has cited this home for F0804 2 times since 2023.

• Citation F0566. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

  CMS lists it as corrected on January 13, 2025.

  CMS has cited this home for F0566 3 times since 2022.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on January 13, 2025.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 13, 2025.

• Citation F0626. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

  CMS lists it as corrected on January 13, 2025.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on January 13, 2025.

  CMS has cited this home for F0677 3 times since 2022.

• 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 13, 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 January 13, 2025.

• 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 January 13, 2025.

  CMS has cited this home for F0685 2 times since 2022.

• 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 13, 2025.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on January 13, 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 January 13, 2025.

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CMS lists this as a standard inspection.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on March 9, 2025.

  CMS has cited this home for K0345 3 times since 2022.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on January 20, 2025.

  CMS has cited this home for K0521 3 times since 2022.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on January 30, 2025.

  CMS has cited this home for K0712 3 times since 2022.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 31, 2025.

  CMS has cited this home for K0918 3 times since 2022.

• Citation K0291. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on January 30, 2025.

  CMS has cited this home for K0291 3 times since 2022.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on January 29, 2025.

  CMS has cited this home for K0321 2 times since 2022.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on February 4, 2025.

  CMS has cited this home for K0324 3 times since 2022.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on February 5, 2025.

  CMS has cited this home for K0353 3 times since 2022.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 29, 2025.

  CMS has cited this home for K0363 3 times since 2022.

• Citation K0911. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on January 30, 2025.

  CMS has cited this home for K0911 3 times since 2022.

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CMS fine of $5,684 on December 19, 2024.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 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 5 of 5 to 4 of 5.

• Name

  CMS lists a new name for this home. It was ARDENT HEALTH AND REHABILITATION CENTER.

• Fine

  CMS changed the fine from October 26, 2023 from $3,679 to $3,741.

CMS lists this as a complaint inspection.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on August 30, 2024.

  CMS has cited this home for F0658 2 times since 2023.

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• Star rating

  The CMS overall 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.

• Fine

  CMS changed the fine from October 26, 2023 from $5,660 to $3,679.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

20 of 210 Colorado homes (10%) got a citation at the immediate jeopardy level in 2024.

• Citation F0686. Severity J: immediate jeopardy, isolated.

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

  CMS lists it as corrected on June 21, 2024.

  CMS has cited this home for F0686 2 times since 2022.

• Citation F0600. Severity G: actual 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 June 21, 2024.

• Citation F0867. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on June 21, 2024.

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CMS fine of $12,058 on June 20, 2024.

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• Star rating

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

• Star rating

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

• Staffing

  Total nurse staffing reported to CMS went from 3.3 to 2.4 hours per resident per day.

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

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

55 of 210 Colorado homes (26%) got a citation at the actual harm level in 2023.

• Citation F0600. Severity G: actual 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 October 27, 2023.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  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 October 27, 2023.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on October 27, 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 October 27, 2023.

• Citation F0566. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

  CMS lists it as corrected on October 27, 2023.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on October 27, 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on October 27, 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on October 27, 2023.

• 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 October 27, 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 October 27, 2023.

• Citation F0774. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Help the resident with transportation to and from laboratory services outside of the facility.

  CMS lists it as corrected on October 27, 2023.

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CMS lists this as a standard inspection.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on January 13, 2024.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 13, 2024.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on January 13, 2024.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on January 13, 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 13, 2024.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on January 13, 2024.

  CMS has cited this home for K0211 2 times since 2022.

• Citation K0291. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on January 13, 2024.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on January 13, 2024.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 13, 2024.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on January 13, 2024.

• Citation K0911. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on January 13, 2024.

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CMS fine of $3,741 on October 26, 2023.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

9 of 210 Colorado homes (4%) got a citation at the immediate jeopardy level in 2022.

• Citation F0689. Severity J: immediate jeopardy, 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 August 23, 2022.

• Citation F0686. Severity G: actual harm, isolated.

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

  CMS lists it as corrected on August 23, 2022.

• Citation F0744. Severity G: actual harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on August 23, 2022.

• Citation F0553. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Allow resident to participate in the development and implementation of his or her person-centered plan of care.

  CMS lists it as corrected on August 23, 2022.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 23, 2022.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on August 23, 2022.

• Citation F0685. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 23, 2022.

• 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 23, 2022.

• Citation F0791. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide or obtain dental services for each resident.

  CMS lists it as corrected on August 23, 2022.

• Citation F0808. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

  CMS lists it as corrected on August 23, 2022.

• Citation F0867. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on August 23, 2022.

• 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 August 23, 2022.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on August 23, 2022.

• Citation F0566. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

  CMS lists it as corrected on August 23, 2022.

• 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 August 23, 2022.

• 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 August 23, 2022.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  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 23, 2022.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on August 23, 2022.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 23, 2022.

• 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 August 23, 2022.

• Citation F0726. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on August 23, 2022.

• 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 August 23, 2022.

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CMS lists this as a standard inspection.

• Citation E0007. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address patient/client population and determine types of services needed.

  CMS lists it as corrected on August 23, 2022.

• Citation E0009. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 23, 2022.

• Citation E0018. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish procedures for tracking staff and patients during an emergency.

  CMS lists it as corrected on August 23, 2022.

• Citation E0023. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on August 23, 2022.

• Citation E0026. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on August 23, 2022.

• Citation E0030. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 23, 2022.

• Citation E0032. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on August 23, 2022.

• Citation E0035. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide family notifications of emergency plan.

  CMS lists it as corrected on August 23, 2022.

• Citation E0036. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on August 23, 2022.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on August 23, 2022.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on August 23, 2022.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on October 13, 2022.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on October 13, 2022.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on October 13, 2022.

• Citation K0363. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on October 13, 2022.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on September 19, 2022.

• Citation K0711. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on October 13, 2022.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on October 13, 2022.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on October 13, 2022.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on October 13, 2022.

• Citation K0222. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on October 13, 2022.

• Citation K0271. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have exits that are accessible at all times.

  CMS lists it as corrected on October 13, 2022.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on October 13, 2022.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on October 13, 2022.

• 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 October 13, 2022.

• 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 October 13, 2022.

• 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 October 13, 2022.

• Citation K0911. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on October 13, 2022.

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