Bria of River Oaks

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 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 3 of 5 to 2 of 5.

• CMS abuse icon

  CMS removed its abuse icon from this home.

CMS lists this as a complaint inspection.

• 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 24, 2026.

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• Star rating

  The CMS quality measures 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 2 of 5.

• Fine

  CMS changed the fine from March 14, 2025 from $35,360 to $22,984.

• Star rating

  The CMS health inspection 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 3 of 5.

CMS lists this as a standard inspection.

• Citation F0838. Severity F: potential for more than minimal harm, widespread.

  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 29, 2025.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  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 29, 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 August 29, 2025.

  CMS has cited this home for F0584 3 times since 2024.

• Citation F0641. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 29, 2025.

• Citation F0645. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 29, 2025.

• Citation F0770. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide timely, quality laboratory services/tests to meet the needs of residents.

  CMS lists it as corrected on August 29, 2025.

• Citation F0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on August 29, 2025.

  CMS has cited this home for F0925 2 times since 2023.

• 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 29, 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 August 29, 2025.

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

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• Fine

  CMS changed the fine from July 13, 2024 from $47,000 to $30,550.

• Fine

  CMS changed the fine from October 10, 2024 from $21,615 to $14,050.

• Fine

  CMS changed the fine from December 3, 2024 from $39,390 to $25,604.

• Star rating

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

• Name

  CMS lists a new legal business name for this home.

CMS lists this as a complaint inspection.

• 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 June 25, 2025.

• Citation F0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on June 25, 2025.

  CMS has cited this home for F0921 3 times since 2023.

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• Star rating

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

CMS lists this as a complaint inspection.

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

362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.

• 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 April 7, 2025.

  CMS has cited this home for F0600 5 times since 2024.

• 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 April 7, 2025.

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CMS lists this as a complaint inspection.

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

362 of 664 Illinois homes (55%) got a citation at the actual harm level in 2025.

• Citation F0684. Severity G: actual 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 March 25, 2025.

  CMS has cited this home for F0684 4 times since 2023.

• Citation F0697. Severity G: actual harm, isolated.

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

  CMS lists it as corrected on March 25, 2025.

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CMS lists this as a complaint inspection.

• 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 March 15, 2025.

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CMS fine of $22,984 on March 14, 2025.

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• 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.

CMS lists this as a complaint inspection.

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

383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.

• 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 December 4, 2024.

• 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 December 4, 2024.

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CMS fine of $25,604 on December 3, 2024.

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CMS lists this as a complaint inspection.

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

383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.

• 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 October 11, 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 October 11, 2024.

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CMS fine of $14,050 on October 10, 2024.

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• Fine

  CMS changed the fine from January 9, 2024 from $127,435 to $82,833.

CMS lists this as a complaint inspection.

• Citation F0803. Severity F: potential for more than minimal harm, widespread.

  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 September 15, 2024.

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CMS lists this as a complaint inspection.

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

383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.

• Citation F0684. Severity G: actual 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 2, 2024.

• Citation F0726. Severity E: potential for more than minimal harm, pattern.

  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 2, 2024.

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CMS lists this as a standard inspection.

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

383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.

• 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 July 14, 2024.

  CMS has cited this home for F0686 2 times since 2023.

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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 July 18, 2024.

  CMS has cited this home for E0007 2 times since 2022.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for E0015 2 times since 2022.

• Citation E0022. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for sheltering.

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for E0022 2 times since 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 July 18, 2024.

  CMS has cited this home for E0039 2 times since 2022.

• Citation K0133. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install a two-hour-resistant firewall separation.

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0133 2 times since 2022.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS has cited this home for K0311 3 times since 2022.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

  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 July 18, 2024.

  CMS has cited this home for K0321 3 times since 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 August 1, 2024.

  CMS has cited this home for K0345 2 times since 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 July 18, 2024.

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

• Citation K0374. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0374 3 times since 2022.

• Citation K0511. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0511 2 times since 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 July 18, 2024.

  CMS has cited this home for K0711 2 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 August 26, 2024.

  CMS has cited this home for K0918 2 times since 2022.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0161 3 times since 2022.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0211 3 times since 2022.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  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 July 18, 2024.

  CMS has cited this home for K0222 2 times since 2023.

• Citation K0225. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0225 2 times since 2023.

• Citation K0226. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have horizontal exits used in accordance with safety requirements.

  CMS lists it as corrected on July 18, 2024.

• Citation K0293. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on July 18, 2024.

• Citation K0324. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on August 1, 2024.

  CMS has cited this home for K0324 2 times since 2022.

• Citation K0351. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 9, 2024.

  CMS has cited this home for K0351 2 times since 2022.

• 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, 2024.

  CMS has cited this home for K0363 2 times since 2023.

• Citation K0741. Severity E: potential for more than minimal harm, pattern.

  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 July 18, 2024.

  CMS has cited this home for K0741 2 times since 2023.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0920 3 times since 2022.

• 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 July 18, 2024.

  CMS has cited this home for K0923 2 times since 2022.

• Citation K0929. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

  CMS lists it as corrected on July 18, 2024.

  CMS has cited this home for K0929 2 times since 2022.

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CMS fine of $30,550 on July 13, 2024.

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• Fine

  CMS changed the fine from November 3, 2023 from $20,060 to $13,039.

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 June 22, 2024.

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CMS stopped payment for new admissions from June 20, 2024, for 2 days.

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CMS lists this as a complaint inspection.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on June 10, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

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

383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.

• 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 22, 2024.

• 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 June 1, 2024.

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CMS fine of $30,602 on May 31, 2024.

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• Fine

  CMS changed the fine from August 3, 2023 from $77,825 to $50,586.

• 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.

• Fine

  CMS changed the fine from January 17, 2023 from $28,380 to $18,447.

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.

129 of 664 Illinois homes (19%) got a citation at the immediate jeopardy level in 2024.

• Citation F0600. Severity J: immediate jeopardy, 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 January 10, 2024.

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CMS fine of $82,833 on January 9, 2024.

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CMS lists this as a complaint inspection.

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

212 of 664 Illinois homes (32%) got a citation at the actual harm level in 2023.

• Citation F0684. Severity G: actual 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 November 4, 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 November 4, 2023.

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CMS fine of $13,039 on November 3, 2023.

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CMS lists this as a standard inspection.

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

212 of 664 Illinois homes (32%) got a citation at the actual harm level in 2023.

• 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 22, 2023.

• 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 August 22, 2023.

• 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 September 11, 2023.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on September 11, 2023.

• Citation F0925. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on August 22, 2023.

• 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 22, 2023.

• 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 August 22, 2023.

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CMS lists this as a standard inspection.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

• 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 August 29, 2023.

• 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 August 23, 2023.

• Citation K0372. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 23, 2023.

• Citation K0374. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on August 23, 2023.

• Citation K0531. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on August 23, 2023.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 23, 2023.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 23, 2023.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  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 August 23, 2023.

• Citation K0225. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  CMS lists it as corrected on August 23, 2023.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  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 August 23, 2023.

• Citation K0355. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on August 23, 2023.

• Citation K0741. Severity E: potential for more than minimal harm, pattern.

  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 August 23, 2023.

• 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 August 23, 2023.

• Citation K0346. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on August 23, 2023.

• Citation K0354. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on August 23, 2023.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on September 5, 2022.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on September 5, 2022.

• 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 September 5, 2022.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on September 5, 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 September 5, 2022.

• Citation E0020. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures including evacuation.

  CMS lists it as corrected on September 5, 2022.

• Citation E0022. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for sheltering.

  CMS lists it as corrected on September 5, 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 September 5, 2022.

• Citation E0024. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on September 5, 2022.

• Citation E0025. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Create arrangements with other facilities to receive patients.

  CMS lists it as corrected on September 5, 2022.

• Citation E0029. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on September 5, 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 September 5, 2022.

• Citation E0031. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on September 5, 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 September 5, 2022.

• Citation E0033. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish methods for sharing information.

  CMS lists it as corrected on September 5, 2022.

• Citation E0034. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide a means of sharing information on occupancy/needs.

  CMS lists it as corrected on September 5, 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 September 5, 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 September 5, 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 September 5, 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 September 5, 2022.

• Citation K0133. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install a two-hour-resistant firewall separation.

  CMS lists it as corrected on September 5, 2022.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

• 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 September 26, 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 7, 2022.

• Citation K0374. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 5, 2022.

• Citation K0511. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 5, 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 September 9, 2022.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 5, 2022.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 5, 2022.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  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 September 5, 2022.

• Citation K0324. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on September 15, 2022.

• Citation K0351. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on October 7, 2022.

• Citation K0711. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 5, 2022.

• Citation K0754. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly sized and located linen or trash receptacles.

  CMS lists it as corrected on September 5, 2022.

• Citation K0781. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on September 5, 2022.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on September 5, 2022.

• 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 September 5, 2022.

• Citation K0929. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

  CMS lists it as corrected on September 5, 2022.

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