Kadima Rehabilitation & Nursing at Cheswick

• 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.

• Ownership

  CMS no longer lists a chain for this home.

• Fine

  CMS changed the fine from April 30, 2026 from $72,725 to $112,925.

CMS lists this as a complaint inspection.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on September 21, 2026.

  CMS has cited this home for F0695 3 times since 2022.

• 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 September 21, 2026.

  CMS has cited this home for F0584 6 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 September 21, 2026.

  CMS has cited this home for F0677 2 times since 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 now lists this home as a Special Focus Facility candidate.

CMS lists this as a complaint inspection.

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

113 of 656 Pennsylvania homes (17%) got a citation at the actual harm level in 2026.

• Citation F0699. Severity G: actual harm, isolated.

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

  CMS lists it as corrected on July 7, 2026.

  CMS has cited this home for F0699 2 times since 2024.

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

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

  CMS lists it as corrected on July 7, 2026.

  CMS has cited this home for F0842 2 times since 2025.

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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.

67 of 656 Pennsylvania homes (10%) got a citation at the immediate jeopardy level in 2026.

• Citation F0689. Severity L: immediate jeopardy, widespread.

  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 3, 2026.

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

• Citation F0941. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  CMS lists it as corrected on June 3, 2026.

• Citation F0942. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  CMS lists it as corrected on June 3, 2026.

• Citation F0943. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  CMS lists it as corrected on June 3, 2026.

• Citation F0944. Severity E: potential for more than minimal harm, pattern.

  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 June 3, 2026.

• Citation F0945. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  CMS lists it as corrected on June 3, 2026.

• Citation F0946. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide training in compliance and ethics.

  CMS lists it as corrected on June 3, 2026.

• 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 July 7, 2026.

• Citation F0949. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide behavior health training consistent with the requirements and as determined by a facility assessment.

  CMS lists it as corrected on June 3, 2026.

• 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 July 7, 2026.

• 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 June 3, 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 June 3, 2026.

  CMS has cited this home for F0684 4 times since 2022.

• Citation F0835. Severity D: potential for more than minimal harm, isolated.

  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 3, 2026.

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CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 18, 2026.

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CMS fine of $112,925 on April 30, 2026.

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• Star rating

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

CMS lists this as 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 April 6, 2026.

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

• 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 April 6, 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 April 6, 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 April 6, 2026.

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• Star rating

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

• Changed ownership in the last 12 months

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

• Ownership

  CMS lists this home under a new chain.

• Star rating

  The CMS staffing star rating changed from not rated by CMS to 3 of 5.

• Star rating

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

• Name

  CMS lists a new legal business name for this home.

• Health citation

  CMS removed citation F0584 from the health inspection on November 14, 2024.

• Fine

  CMS changed the fine from March 20, 2023 from $15,265 to $7,633.

CMS lists this as a complaint inspection.

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

67 of 656 Pennsylvania homes (10%) got a citation at the immediate jeopardy level in 2025.

• 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 November 25, 2025.

• Citation F0742. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

  CMS lists it as corrected on November 25, 2025.

• Citation F0868. Severity D: potential for more than minimal harm, isolated.

  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 November 25, 2025.

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CMS fine of $15,157 on October 31, 2025.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to not rated by CMS.

• Star rating

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

• Changed ownership in the last 12 months

  CMS records show a change of ownership in the past 12 months.

• Health citation

  CMS removed citation F0622 from the health inspection on November 7, 2024.

• Health citation

  CMS removed citation F0623 from the health inspection on November 7, 2024.

• Health citation

  CMS removed citation F0625 from the health inspection on November 7, 2024.

CMS lists this as a complaint inspection.

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

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on August 2, 2025.

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• Star rating

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

CMS lists this as a complaint inspection.

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

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

  CMS lists it as corrected on June 30, 2025.

  CMS has cited this home for F0610 2 times since 2024.

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• Name

  CMS lists a new legal business name for this home.

CMS lists this as a complaint inspection.

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

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

  CMS lists it as corrected on April 28, 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 April 28, 2025.

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

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

  CMS lists it as corrected on April 28, 2025.

• Citation F0805. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on April 28, 2025.

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• Name

  CMS lists a new name for this home. It was CHESWICK REHABILITATION AND WELLNESS CENTER, LLC.

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 March 4, 2025.

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CMS lists this as a complaint inspection.

• Citation F0570. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Assure the security of all personal funds of residents deposited with the facility.

  CMS lists it as corrected on February 10, 2025.

• Citation F0826. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.

  CMS lists it as corrected on February 10, 2025.

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CMS lists this as a complaint inspection.

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

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on December 20, 2024.

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CMS lists this as a standard 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 December 20, 2024.

• Citation F0622. Severity E: potential for more than minimal harm, pattern.

  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 December 20, 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 December 20, 2024.

• Citation F0699. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on December 20, 2024.

• Citation F0849. Severity E: potential for more than minimal harm, pattern.

  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 December 20, 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 December 20, 2024.

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

• 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 December 20, 2024.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on December 20, 2024.

  CMS has cited this home for F0600 2 times since 2023.

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

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

  CMS lists it as corrected on December 20, 2024.

• Citation F0620. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

  CMS lists it as corrected on December 20, 2024.

• 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 December 20, 2024.

• 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 December 20, 2024.

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

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

  CMS lists it as corrected on December 20, 2024.

  CMS has cited this home for F0726 2 times since 2022.

• Citation F0773. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

  CMS lists it as corrected on December 20, 2024.

• Citation F0810. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide special eating equipment and utensils for residents who need them and appropriate assistance.

  CMS lists it as corrected on December 20, 2024.

• Citation F0623. Severity C: potential for minimal harm, widespread.

  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 December 20, 2024.

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CMS lists this as a standard inspection.

• 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 November 22, 2024.

  CMS has cited this home for K0363 2 times since 2022.

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• Star rating

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

• Star rating

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

• Star rating

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

• Star rating

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

• Fine

  CMS changed the fine from March 20, 2023 from $14,885 to $15,265.

CMS lists this as a complaint inspection.

• 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 June 10, 2024.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on June 10, 2024.

  CMS has cited this home for F0692 3 times since 2022.

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• Ownership

  CMS lists this home under a new chain.

• Ownership

  CMS lists this home under a new chain.

• Fine

  CMS changed the fine from March 20, 2023 from $22,900 to $14,885.

• Star rating

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

CMS lists this as a standard inspection.

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

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

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

• Citation F0569. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

  CMS lists it as corrected on January 26, 2024.

• 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 January 26, 2024.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on January 26, 2024.

• 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 January 26, 2024.

• 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 January 26, 2024.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 26, 2024.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 26, 2024.

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

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

  CMS lists it as corrected on January 26, 2024.

• Citation F0847. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

  CMS lists it as corrected on January 26, 2024.

• Citation F0919. Severity D: potential for more than minimal harm, isolated.

  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 January 26, 2024.

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CMS lists this as a standard inspection.

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

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

  CMS lists it as corrected on January 19, 2024.

• 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 January 19, 2024.

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

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on January 19, 2024.

• 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 January 19, 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 January 19, 2024.

• Citation K0353. Severity C: potential for minimal harm, widespread.

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

  CMS lists it as corrected on January 19, 2024.

  CMS has cited this home for K0353 2 times since 2022.

• Citation K0918. Severity C: potential for minimal harm, widespread.

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

  CMS lists it as corrected on January 19, 2024.

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CMS lists this as a standard inspection.

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

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

  CMS lists it as corrected on February 8, 2023.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on February 8, 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 February 8, 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 February 8, 2023.

• Citation F0680. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the activities program is directed by a qualified professional.

  CMS lists it as corrected on February 8, 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 February 8, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 8, 2023.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 8, 2023.

• 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 February 8, 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 February 8, 2023.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 8, 2023.

• 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 February 8, 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 February 8, 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 February 8, 2023.

• Citation F0838. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  CMS lists it as corrected on February 8, 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 February 8, 2023.

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CMS lists this as a standard inspection.

• 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 17, 2023.

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

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

  CMS lists it as corrected on January 17, 2023.

• Citation K0345. Severity C: potential for minimal harm, widespread.

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

  CMS lists it as corrected on January 17, 2023.

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