Horizon Post Acute

• Star rating

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

• Star rating

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

• Name

  CMS lists a new name for this home. It was LEGACY AT COLLEGE HILL.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

CMS lists this as a standard inspection and 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.

22 of 296 Kansas homes (7%) got a citation at the immediate jeopardy level in 2026.

• 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 June 30, 2026.

  CMS has cited this home for F0689 4 times since 2023.

• Citation F0565. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on June 30, 2026.

• 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 30, 2026.

  CMS has cited this home for F0584 3 times since 2023.

• 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 June 30, 2026.

• 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 June 30, 2026.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on June 30, 2026.

  CMS has cited this home for F0644 2 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 June 30, 2026.

  CMS has cited this home for F0657 3 times since 2024.

• 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 June 30, 2026.

• 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 June 30, 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 June 30, 2026.

  CMS has cited this home for F0690 3 times since 2023.

• 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 June 30, 2026.

• 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 June 30, 2026.

  CMS has cited this home for F0698 2 times since 2025.

• Citation F0804. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on June 30, 2026.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on June 30, 2026.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on June 30, 2026.

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CMS lists this as a standard inspection.

• 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 19, 2026.

  CMS has cited this home for E0009 2 times since 2025.

• 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 19, 2026.

• 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 July 31, 2026.

  CMS has cited this home for K0372 2 times since 2025.

• 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 July 31, 2026.

  CMS has cited this home for K0712 3 times since 2023.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on July 31, 2026.

  CMS has cited this home for K0761 2 times since 2025.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on August 7, 2026.

  CMS has cited this home for K0914 3 times since 2023.

• 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 July 31, 2026.

  CMS has cited this home for K0918 3 times since 2023.

• 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 31, 2026.

  CMS has cited this home for K0363 2 times since 2025.

• 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 July 31, 2026.

• 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 July 31, 2026.

  CMS has cited this home for K0321 3 times since 2023.

• 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 July 31, 2026.

  CMS has cited this home for K0741 3 times since 2023.

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CMS fine of $26,446 on June 3, 2026.

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• Fine

  CMS changed the fine from March 12, 2025 from $8,281 to $8,413.

CMS lists this as a complaint inspection.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on May 1, 2026.

  CMS has cited this home for K0211 2 times since 2025.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  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 May 1, 2026.

  CMS has cited this home for K0222 3 times since 2023.

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• Star rating

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

• Fine

  CMS changed the fine from March 12, 2025 from $12,740 to $8,281.

• Star rating

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

• Ownership

  CMS lists this home under a new chain.

• Star rating

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

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Fine

  CMS changed the fine from July 30, 2024 from $53,500 to $34,775.

• Health citation

  CMS removed citation F0625 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0758 from the health inspection on February 13, 2025.

CMS lists this as a complaint inspection.

• 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 June 20, 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 June 20, 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 June 20, 2025.

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CMS stopped payment for new admissions from March 29, 2025, for 10 days.

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CMS fine of $8,413 on March 12, 2025.

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• 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 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

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

• 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 March 7, 2025.

  CMS has cited this home for F0880 3 times since 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 March 7, 2025.

• 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 March 7, 2025.

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

• Citation F0883. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on March 7, 2025.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  CMS lists it as corrected on March 7, 2025.

• 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 March 7, 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 March 7, 2025.

• 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 March 7, 2025.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on March 7, 2025.

• 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 March 7, 2025.

  CMS has cited this home for F0756 2 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 March 7, 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 March 7, 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 March 7, 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 March 7, 2025.

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CMS lists this as a standard inspection.

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

54 of 296 Kansas homes (18%) got a citation at the immediate jeopardy level in 2025.

• Citation K0345. Severity L: immediate jeopardy, widespread.

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

  CMS lists it as corrected on April 8, 2025.

  CMS has cited this home for K0345 2 times since 2023.

• 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 April 7, 2025.

  CMS has cited this home for E0004 2 times since 2023.

• 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 April 7, 2025.

• 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 April 8, 2025.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on April 7, 2025.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  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 April 8, 2025.

• 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 April 7, 2025.

• 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 March 12, 2025.

  CMS has cited this home for K0353 2 times since 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 April 7, 2025.

• 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 April 7, 2025.

• 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 April 8, 2025.

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

• 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 March 12, 2025.

  CMS has cited this home for K0521 2 times since 2023.

• 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 April 7, 2025.

• Citation K0741. Severity F: potential for more than minimal harm, widespread.

  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 April 7, 2025.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on March 12, 2025.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on April 7, 2025.

• 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 March 12, 2025.

• Citation K0920. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on April 7, 2025.

  CMS has cited this home for K0920 2 times since 2023.

• Citation K0923. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on April 7, 2025.

• 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 April 7, 2025.

  CMS has cited this home for K0324 2 times since 2023.

• Citation K0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that sources of ignition are removed from patients receiving respiratory therapy.

  CMS lists it as corrected on April 8, 2025.

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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 3 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 5 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.

61 of 296 Kansas homes (21%) 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 August 23, 2024.

• 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 23, 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 August 23, 2024.

• 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 August 23, 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 August 23, 2024.

  CMS has cited this home for F0755 2 times since 2023.

• 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, 2024.

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CMS fine of $34,775 on July 30, 2024.

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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 May 2, 2023 from $67,170 to $43,661.

• Star rating

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

CMS lists this as a standard inspection.

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

25 of 296 Kansas homes (8%) got a citation at the immediate jeopardy level in 2023.

• Citation F0600. Severity L: immediate jeopardy, widespread.

  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 15, 2023.

• Citation F0610. Severity L: immediate jeopardy, widespread.

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

  CMS lists it as corrected on June 15, 2023.

• Citation F0609. Severity K: immediate jeopardy, pattern.

  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 June 15, 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 June 15, 2023.

• Citation F0584. Severity F: potential for more than minimal harm, widespread.

  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 15, 2023.

• Citation F0725. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on June 15, 2023.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  CMS lists it as corrected on June 15, 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 June 15, 2023.

• Citation F0835. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on June 15, 2023.

• Citation F0868. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  CMS lists it as corrected on June 15, 2023.

• 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 June 15, 2023.

• Citation F0919. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on June 15, 2023.

• Citation F0700. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  CMS lists it as corrected on June 15, 2023.

• Citation F0741. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

  CMS lists it as corrected on June 15, 2023.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  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 June 15, 2023.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  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 June 15, 2023.

• 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 June 15, 2023.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on June 15, 2023.

• Citation F0646. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

  CMS lists it as corrected on June 15, 2023.

• 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 June 15, 2023.

• 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 June 15, 2023.

• 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 June 15, 2023.

• Citation F0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  CMS lists it as corrected on June 15, 2023.

• Citation F0730. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on June 15, 2023.

• 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 15, 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 July 26, 2023.

• 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 26, 2023.

• 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 July 26, 2023.

• 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 July 26, 2023.

• 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 July 26, 2023.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  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 26, 2023.

• 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 26, 2023.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on July 26, 2023.

• 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 July 26, 2023.

• 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 26, 2023.

• Citation K0355. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 26, 2023.

• Citation K0371. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly sized and located compartments to protect residents from smoke.

  CMS lists it as corrected on July 26, 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 July 26, 2023.

• 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 26, 2023.

• 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 July 26, 2023.

• 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 July 26, 2023.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on July 26, 2023.

• 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 July 26, 2023.

• Citation K0920. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 26, 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 26, 2023.

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