Inspection visit
Inspection
Citations
23 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F584 - Safe Environment
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.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0100GeneralS&S Fpotential for harm
Meet other general requirements.
- 0200GeneralS&S Epotential for harm
Meet other general requirements.
- 0291GeneralS&S Epotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the February 29, 2024 survey of NANCY HART OPERATION LLC?
This was a inspection survey of NANCY HART OPERATION LLC on February 29, 2024. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NANCY HART OPERATION LLC on February 29, 2024?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.