Casa De Oro Center

• Special Focus Facility

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

• Star rating

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

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 June 24, 2026.

  CMS has cited this home for F0842 7 times since 2023.

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• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

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

CMS lists this as a complaint inspection.

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

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

  CMS lists it as corrected on May 1, 2026.

  CMS has cited this home for F0760 2 times since 2025.

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

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

  CMS lists it as corrected on May 1, 2026.

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• Fine

  CMS changed the fine from May 13, 2025 from $53,100 to $34,515.

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

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

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

  CMS lists it as corrected on March 18, 2026.

  CMS has cited this home for F0812 3 times since 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 March 18, 2026.

  CMS has cited this home for F0550 2 times since 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 March 18, 2026.

  CMS has cited this home for F0657 6 times since 2023.

• 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 March 18, 2026.

  CMS has cited this home for F0658 4 times since 2023.

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

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

  CMS lists it as corrected on March 18, 2026.

  CMS has cited this home for F0761 4 times since 2023.

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

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

  CMS lists it as corrected on March 18, 2026.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  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 March 18, 2026.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on March 18, 2026.

• 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 March 18, 2026.

• 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 March 18, 2026.

  CMS has cited this home for F0684 2 times since 2024.

• Citation F0687. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate foot care.

  CMS lists it as corrected on March 18, 2026.

• 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 18, 2026.

  CMS has cited this home for F0756 3 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 March 18, 2026.

  CMS has cited this home for F0880 2 times since 2023.

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• Star rating

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

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 December 10, 2025.

  CMS has cited this home for F0609 5 times since 2024.

• Citation F0610. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on October 1, 2025.

• 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 December 10, 2025.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  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 October 1, 2025.

  CMS has cited this home for F0755 2 times since 2024.

• Citation F0760. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on December 10, 2025.

• 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 December 10, 2025.

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• Star rating

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

• Health citation

  CMS removed citation F0622 from the health inspection on March 3, 2025.

• Health citation

  CMS removed citation F0660 from the health inspection on March 3, 2025.

• Health citation

  CMS removed citation F0661 from the health inspection on March 3, 2025.

CMS stopped payment for new admissions from June 12, 2025, for 28 days.

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CMS lists this as a complaint inspection.

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

11 of 68 New Mexico homes (16%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity K: immediate jeopardy, pattern.

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

  CMS lists it as corrected on July 10, 2025.

  CMS has cited this home for F0689 2 times since 2024.

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

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

  CMS lists it as corrected on July 10, 2025.

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

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

  CMS lists it as corrected on July 10, 2025.

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CMS fine of $34,515 on May 13, 2025.

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• Fine

  CMS changed the fine from October 28, 2024 from $52,367 to $34,039.

CMS lists this as a complaint inspection.

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

  The rule CMS cited: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

  CMS lists it as corrected on April 11, 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 April 11, 2025.

• Citation F0660. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Plan the resident's discharge to meet the resident's goals and needs.

  CMS lists it as corrected on April 11, 2025.

• Citation F0661. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  CMS lists it as corrected on April 11, 2025.

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

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

  CMS lists it as corrected on April 11, 2025.

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CMS lists this as a complaint inspection.

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

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

  CMS lists it as corrected on November 24, 2024.

  CMS has cited this home for F0686 2 times since 2024.

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CMS stopped payment for new admissions from November 13, 2024, for 6 days.

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• Health citation

  CMS changed citation F0609 from severity E to D. It is from the health inspection on June 20, 2024. Severity D: potential for more than minimal harm, isolated.

• Health citation

  CMS changed citation F0623 from severity E to D. It is from the health inspection on June 20, 2024. Severity D: potential for more than minimal harm, isolated.

• Health citation

  CMS changed citation F0625 from severity E to D. It is from the health inspection on June 20, 2024. Severity D: potential for more than minimal harm, isolated.

• Health citation

  CMS changed citation F0657 from severity E to D. It is from the health inspection on June 20, 2024. Severity D: potential for more than minimal harm, isolated.

• Health citation

  CMS changed citation F0842 from severity E to D. It is from the health inspection on June 20, 2024. Severity D: potential for more than minimal harm, isolated.

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

Severity K 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 F0600. Severity K: immediate jeopardy, 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 November 19, 2024.

• 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 November 19, 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 November 19, 2024.

• Citation F0947. Severity F: potential for more than minimal harm, widespread.

  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 November 19, 2024.

  CMS has cited this home for F0947 2 times since 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 November 19, 2024.

  CMS has cited this home for F0584 3 times since 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 November 19, 2024.

  CMS has cited this home for F0656 2 times since 2023.

• 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 November 19, 2024.

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

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

  CMS lists it as corrected on November 19, 2024.

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

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

  CMS lists it as corrected on November 19, 2024.

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

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

  CMS lists it as corrected on November 19, 2024.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  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 November 19, 2024.

  CMS has cited this home for F0725 2 times since 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 November 19, 2024.

  CMS has cited this home for F0758 3 times since 2023.

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

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

  CMS lists it as corrected on November 19, 2024.

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

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

  CMS lists it as corrected on November 19, 2024.

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

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

  CMS lists it as corrected on November 19, 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 November 19, 2024.

• 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 November 19, 2024.

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

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

  CMS lists it as corrected on November 19, 2024.

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

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on November 19, 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 19, 2024.

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

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

  CMS lists it as corrected on November 19, 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 November 19, 2024.

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CMS lists this as a standard inspection.

• 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 November 7, 2024.

  CMS has cited this home for K0353 2 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 November 7, 2024.

  CMS has cited this home for K0918 2 times since 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 November 7, 2024.

  CMS has cited this home for K0321 2 times since 2023.

• Citation K0911. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on November 7, 2024.

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

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

  CMS lists it as corrected on November 7, 2024.

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CMS fine of $34,039 on October 28, 2024.

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• Star rating

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

• Star rating

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

• Special Focus Facility

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

CMS lists this as a complaint inspection.

• 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 August 6, 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 August 6, 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.

  CMS lists it as corrected on August 6, 2024.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  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 August 6, 2024.

  CMS has cited this home for F0623 3 times since 2023.

• 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 August 6, 2024.

  CMS has cited this home for F0625 3 times since 2023.

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

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

  CMS lists it as corrected on August 6, 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 August 6, 2024.

• Citation F0584. Severity C: potential for 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 August 6, 2024.

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• CMS abuse icon

  CMS added its abuse icon to this home.

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Fine

  CMS changed the fine from September 24, 2021 from $9,750 to $10,641.

CMS lists this as a complaint inspection.

• 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 March 26, 2024.

• Citation F0559. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS lists it as corrected on March 26, 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 March 26, 2024.

  CMS has cited this home for F0580 2 times since 2023.

• Citation F0603. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

  CMS lists it as corrected on March 26, 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 March 26, 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 March 26, 2024.

• 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 March 26, 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 March 26, 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 March 26, 2024.

• 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 March 26, 2024.

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CMS stopped payment for new admissions from February 20, 2024, for 35 days.

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CMS lists this as a standard inspection and a complaint 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 January 18, 2024.

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

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

  CMS lists it as corrected on January 18, 2024.

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

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

  CMS lists it as corrected on January 18, 2024.

• Citation F0568. Severity E: potential for more than minimal harm, pattern.

  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 January 18, 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 January 18, 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 January 18, 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 January 18, 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 January 18, 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 January 18, 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 January 18, 2024.

• Citation F0688. Severity E: potential for more than minimal harm, pattern.

  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 January 18, 2024.

• 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 January 18, 2024.

• 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 January 18, 2024.

• 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 January 18, 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 January 18, 2024.

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

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

  CMS lists it as corrected on January 18, 2024.

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

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

  CMS lists it as corrected on January 18, 2024.

• Citation F0806. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on January 18, 2024.

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

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

  CMS lists it as corrected on January 18, 2024.

• Citation F0825. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on January 18, 2024.

• 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 January 18, 2024.

• 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 January 18, 2024.

• 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 January 18, 2024.

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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 January 18, 2024.

• 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 January 18, 2024.

• 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 January 18, 2024.

• 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 January 18, 2024.

• Citation K0223. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  CMS lists it as corrected on February 20, 2024.

• 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 February 20, 2024.

• 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 February 20, 2024.

• Citation K0351. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on February 20, 2024.

• Citation K0364. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install properly constructed windows in hallway walls or doors.

  CMS lists it as corrected on January 18, 2024.

• 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 January 18, 2024.

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

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

  CMS lists it as corrected on February 20, 2024.

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

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

  CMS lists it as corrected on January 18, 2024.

• Citation K0912. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on February 20, 2024.

• 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 January 18, 2024.

• Citation K0362. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

  CMS lists it as corrected on February 20, 2024.

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CMS lists this as a standard inspection.

• 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 April 3, 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 April 3, 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 April 3, 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 April 3, 2023.

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