Casa Arena Healthcare LLC

CMS lists this as a complaint inspection.

• 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 May 30, 2026.

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

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CMS lists this as a complaint inspection.

• Citation F0842. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on April 18, 2026.

  CMS has cited this home for F0842 4 times since 2024.

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

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

  The home is disputing this citation through CMS's informal review.

  CMS lists it as corrected on April 18, 2026.

  CMS has cited this home for F0609 5 times since 2023.

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

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

  The home is disputing this citation through CMS's informal review.

  CMS lists it as corrected on April 18, 2026.

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

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

  CMS lists it as corrected on April 18, 2026.

  CMS has cited this home for F0657 4 times since 2024.

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CMS lists this as a complaint inspection.

• 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 January 17, 2026.

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• Star rating

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

• Special Focus Facility

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

• Ownership

  CMS lists this home under a new chain.

• Star rating

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

CMS lists this as a complaint inspection.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  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 20, 2025.

  CMS has cited this home for F0584 4 times since 2023.

• Citation F0636. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS lists it as corrected on August 20, 2025.

  CMS has cited this home for F0636 2 times since 2023.

• Citation F0637. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on August 20, 2025.

  CMS has cited this home for F0637 3 times since 2023.

• 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 August 20, 2025.

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• Health citation

  CMS removed citation F0623 from the health inspection on April 24, 2024.

• Health citation

  CMS removed citation F0625 from the health inspection on April 24, 2024.

• Health citation

  CMS removed citation F0758 from the health inspection on April 24, 2024.

CMS lists this as a standard inspection.

• 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 July 20, 2025.

• Citation F0851. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  CMS lists it as corrected on July 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 July 20, 2025.

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

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

  CMS lists it as corrected on July 20, 2025.

• Citation F0657. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on July 20, 2025.

• Citation F0740. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on July 20, 2025.

• Citation F0744. Severity E: potential for more than minimal harm, pattern.

  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 July 20, 2025.

• 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 July 20, 2025.

  CMS has cited this home for F0756 2 times since 2023.

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

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

  CMS lists it as corrected on July 20, 2025.

  CMS has cited this home for F0812 2 times since 2024.

• 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 July 20, 2025.

  CMS has cited this home for F0550 2 times since 2023.

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

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

  CMS lists it as corrected on July 20, 2025.

  CMS has cited this home for F0580 3 times since 2023.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on July 20, 2025.

  CMS has cited this home for F0641 3 times since 2023.

• 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 July 20, 2025.

  CMS has cited this home for F0655 4 times since 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 July 20, 2025.

  CMS has cited this home for F0656 4 times since 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 July 20, 2025.

  CMS has cited this home for F0658 2 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 July 20, 2025.

• 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 July 20, 2025.

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

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

  CMS lists it as corrected on July 20, 2025.

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

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

  CMS lists it as corrected on July 20, 2025.

  CMS has cited this home for F0880 3 times since 2023.

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CMS lists this as a standard inspection.

• 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 20, 2025.

• Citation K0911. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 20, 2025.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on July 20, 2025.

  CMS has cited this home for K0353 2 times since 2023.

• Citation K0912. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have power receptacles that are properly grounded.

  CMS lists it as corrected on July 20, 2025.

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• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

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

• Special Focus Facility

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

• Fine

  CMS changed the fine from April 24, 2024 from $166,640 to $108,316.

CMS lists this as a complaint inspection.

• Citation F0609. Severity E: potential for more than minimal harm, 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 November 20, 2024.

• 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 November 20, 2024.

• 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 November 20, 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 November 20, 2024.

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• Fine

  CMS changed the fine from April 24, 2024 from $134,045 to $166,640.

CMS lists this as a complaint inspection.

• 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 September 18, 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 September 18, 2024.

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• Star rating

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

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Changed ownership in the last 12 months

  CMS no longer shows a change of ownership in the past 12 months.

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.

20 of 68 New Mexico homes (29%) got a citation at the immediate jeopardy level in 2024.

• Citation F0684. Severity J: immediate jeopardy, isolated.

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

  CMS lists it as corrected on May 23, 2024.

  CMS has cited this home for F0684 2 times since 2023.

• Citation F0583. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0585. Severity F: potential for more than minimal harm, widespread.

  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 May 23, 2024.

• 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 May 23, 2024.

• Citation F0944. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  CMS lists it as corrected on May 23, 2024.

• Citation F0558. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0580. Severity E: potential for more than minimal harm, pattern.

  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 May 23, 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 May 23, 2024.

• Citation F0609. Severity E: potential for more than minimal harm, 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 May 23, 2024.

• Citation F0623. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on May 23, 2024.

  CMS has cited this home for F0623 2 times since 2023.

• Citation F0625. Severity E: potential for more than minimal harm, pattern.

  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 May 23, 2024.

  CMS has cited this home for F0625 2 times since 2023.

• Citation F0637. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on May 23, 2024.

• Citation F0638. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Assure that each resident’s assessment is updated at least once every 3 months.

  CMS lists it as corrected on May 23, 2024.

• Citation F0655. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0657. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0678. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS lists it as corrected on May 23, 2024.

• Citation F0692. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0697. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0757. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

• 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 May 23, 2024.

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

• Citation F0842. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 23, 2024.

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

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

  CMS lists it as corrected on May 23, 2024.

• Citation F0887. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  CMS lists it as corrected on May 23, 2024.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 23, 2024.

• 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 May 23, 2024.

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

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on May 23, 2024.

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CMS lists this as a standard inspection.

• 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 May 21, 2024.

  CMS has cited this home for K0761 2 times since 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 May 21, 2024.

• 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 May 21, 2024.

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CMS fine of $108,316 on April 24, 2024.

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• Fine

  CMS changed the fine from October 24, 2023 from $24,705 to $16,058.

• Fine

  CMS changed the fine from August 13, 2021 from $10,000 to $10,916.

• 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.

• Ownership

  CMS lists this home under a new chain.

• Ownership

  CMS lists this home under a new chain.

CMS lists this as a complaint 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.

8 of 68 New Mexico homes (12%) got a citation at the immediate jeopardy level in 2023.

• Citation F0726. Severity L: immediate jeopardy, widespread.

  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 November 15, 2023.

• Citation F0760. Severity G: actual harm, isolated.

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

  CMS lists it as corrected on November 15, 2023.

• Citation F0919. Severity E: potential for more than minimal harm, pattern.

  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 November 15, 2023.

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

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

  CMS lists it as corrected on November 15, 2023.

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CMS fine of $16,059 on October 24, 2023.

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CMS lists this as a standard inspection.

• Citation F0577. Severity F: potential for more than 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 May 15, 2023.

• 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 May 15, 2023.

• 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 May 15, 2023.

• Citation F0600. Severity E: potential for more than minimal harm, pattern.

  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 May 15, 2023.

• Citation F0623. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on May 15, 2023.

• Citation F0625. Severity E: potential for more than minimal harm, pattern.

  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 May 15, 2023.

• Citation F0637. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on May 15, 2023.

• Citation F0640. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

  CMS lists it as corrected on May 15, 2023.

• 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 May 15, 2023.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 15, 2023.

• Citation F0690. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 15, 2023.

• Citation F0730. Severity E: potential for more than minimal harm, pattern.

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

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

• Citation F0759. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 15, 2023.

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

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on May 15, 2023.

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

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

  CMS lists it as corrected on May 15, 2023.

• Citation F0947. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on May 15, 2023.

• Citation F0568. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

  CMS lists it as corrected on May 15, 2023.

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

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on May 15, 2023.

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

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

  CMS lists it as corrected on May 15, 2023.

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

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

  CMS lists it as corrected on May 15, 2023.

• Citation F0636. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS lists it as corrected on May 15, 2023.

• 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 May 15, 2023.

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

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

  CMS lists it as corrected on May 15, 2023.

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

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on May 15, 2023.

• Citation F0825. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or get specialized rehabilitative services as required for a resident.

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

• 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 May 15, 2023.

• Citation K0293. Severity F: potential for more than minimal harm, widespread.

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

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

• Citation K0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on May 15, 2023.

• Citation K0927. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

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

• 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 May 15, 2023.

• Citation K0325. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly installed hallway dispensers for alcohol-based hand rub.

  CMS lists it as corrected on May 15, 2023.

• Citation K0511. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 15, 2023.

• Citation K0521. Severity E: potential for more than minimal harm, pattern.

  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 May 15, 2023.

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