Safety Report: Colonial Gardens Nursing Home
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
1Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
25Requirements cited on more than one inspection
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F604
Citations by topic
13Abuse, neglect & exploitation
7Infection control
12Medications & pharmacy
6Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (33) than in the cycle before (44).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 9 | March 16, 2026; December 30, 2025; November 14, 2025; August 15, 2025; May 22, 2025; March 10, 2025; August 21, 2024; June 27, 2024; April 8, 2022 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 6 | August 21, 2026; March 16, 2026; November 14, 2025; August 6, 2025; June 24, 2025; April 8, 2022 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 6 | June 24, 2025; April 2, 2025; March 10, 2025; September 13, 2024; June 27, 2024; April 8, 2022 |
| Provide and implement an infection prevention and control program. (F880) | 5 | May 22, 2025; March 10, 2025; November 18, 2024; June 27, 2024; April 8, 2022 |
| Ensure each resident receives an accurate assessment. (F641) | 4 | March 16, 2026; May 22, 2025; June 27, 2024; April 8, 2022 |
| 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. (F761) | 4 | December 30, 2025; May 22, 2025; June 27, 2024; April 8, 2022 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580) | 4 | November 14, 2025; June 24, 2025; August 21, 2024; June 27, 2024 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 3 | August 21, 2026; April 2, 2026; June 27, 2024 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 3 | April 2, 2026; August 6, 2025; June 27, 2024 |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F867) | 3 | August 6, 2025; June 27, 2024; April 8, 2022 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 3 | August 6, 2025; May 22, 2025; April 8, 2022 |
| Respond appropriately to all alleged violations. (F610) | 3 | August 6, 2025; June 24, 2025; April 8, 2022 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | May 22, 2025; June 27, 2024; April 8, 2022 |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. (F911) | 3 | May 22, 2025; June 27, 2024; April 8, 2022 |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. (F912) | 3 | May 22, 2025; June 27, 2024; April 8, 2022 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 3 | March 10, 2025; August 5, 2024; April 8, 2022 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 2 | February 18, 2026; June 27, 2024 |
| 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. (F726) | 2 | December 4, 2025; April 8, 2022 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | May 22, 2025; June 27, 2024 |
| Reasonably accommodate the needs and preferences of each resident. (F558) | 2 | May 22, 2025; June 27, 2024 |
| Ensure that residents are fully informed and understand their health status, care and treatments. (F552) | 2 | May 22, 2025; June 27, 2024 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | May 22, 2025; April 8, 2022 |
| 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. (F758) | 2 | June 27, 2024; April 8, 2022 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 2 | June 27, 2024; April 8, 2022 |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (F604) | 2 | June 27, 2024; April 8, 2022 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| August 5, 2024 | Fine | $36,700 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 21, 2026 — 2 citations · complaint investigation
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected September 11, 2026
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected September 11, 2026
April 2, 2026 — 2 citations · complaint investigation
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected May 1, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected May 1, 2026
March 16, 2026 — 3 citations · complaint investigation
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected April 15, 2026
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected April 15, 2026
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 15, 2026
February 18, 2026 — 1 citation · complaint investigation
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected March 14, 2026
December 30, 2025 — 2 citations · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · complaint · corrected January 12, 2026
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected January 12, 2026
December 4, 2025 — 1 citation · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F726 · complaint · corrected December 28, 2025
November 18, 2025 — 1 citation · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected December 5, 2025
November 14, 2025 — 3 citations · complaint investigation
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected December 14, 2025
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected December 14, 2025
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected December 14, 2025
August 15, 2025 — 1 citation · complaint investigation
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected September 14, 2025
August 6, 2025 — 5 citations · complaint investigation
D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F867 · complaint · corrected August 21, 2025
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected August 21, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected August 21, 2025
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected August 21, 2025
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected August 21, 2025
June 24, 2025 — 4 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected July 24, 2025
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected July 24, 2025
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected July 24, 2025
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected July 24, 2025
May 22, 2025 — 18 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected June 21, 2025
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Pharmacy Service Deficiencies · F761 · corrected June 21, 2025
E
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F911 · corrected June 21, 2025
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected June 21, 2025
D
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F919 · corrected June 21, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected June 21, 2025
D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F808 · corrected June 21, 2025
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected June 21, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected June 21, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected June 21, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected June 21, 2025
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected June 21, 2025
D
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F637 · corrected June 21, 2025
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F628 · corrected June 21, 2025
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected June 21, 2025
D
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F552 · corrected June 21, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected June 21, 2025
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected June 21, 2025
April 16, 2025 — 1 citation · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · complaint · corrected May 16, 2025
April 2, 2025 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected May 2, 2025
March 10, 2025 — 4 citations · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected April 9, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected April 9, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected April 9, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected April 9, 2025
November 18, 2024 — 1 citation · complaint investigation
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected November 24, 2024
September 13, 2024 — 1 citation (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected September 23, 2024
August 21, 2024 — 4 citations · complaint investigation
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · complaint · corrected September 9, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected September 9, 2024
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected September 9, 2024
D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F553 · complaint · corrected September 9, 2024
August 5, 2024 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected August 16, 2024
June 27, 2024 — 27 citations
F
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F881 · corrected July 26, 2024
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected July 26, 2024
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected July 26, 2024
F
Have a plan that describes the process for conducting QAPI and QAA activities.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F865 · corrected July 26, 2024
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected July 26, 2024
E
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F911 · corrected July 26, 2024
E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F883 · corrected July 26, 2024
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected July 26, 2024
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected July 26, 2024
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F758 · corrected July 26, 2024
E
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F552 · corrected July 26, 2024
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected July 26, 2024
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · corrected July 26, 2024
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected July 26, 2024
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected July 26, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected July 26, 2024
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected July 26, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected July 26, 2024
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected July 26, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected July 26, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected July 26, 2024
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected July 26, 2024
D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected July 26, 2024
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected July 26, 2024
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · corrected July 26, 2024
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected July 26, 2024
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected July 26, 2024
April 8, 2022 — 25 citations (includes serious)
G
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected May 20, 2022
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · corrected May 20, 2022
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected May 20, 2022
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F803 · corrected May 20, 2022
F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected May 20, 2022
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected May 20, 2022
E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F867 · corrected May 20, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected May 20, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F758 · corrected May 20, 2022
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected May 20, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected May 20, 2022
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected May 20, 2022
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · corrected May 20, 2022
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected May 20, 2022
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected May 20, 2022
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · corrected May 20, 2022
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected May 20, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F578 · corrected May 20, 2022
D
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F911 · corrected May 20, 2022
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected May 20, 2022
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected May 20, 2022
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected May 20, 2022
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected May 20, 2022
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected May 20, 2022
B
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Pattern · Nursing and Physician Services Deficiencies · F732 · corrected May 20, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare