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Inspection visit

Health inspection

Embassy Rehab and Care CenterCMS #16514536 citations on this visit
36 citations recorded

Citations

36 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.

  • 0577GeneralS&S Epotential for harm

    F577 - The resident has the right to-

    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

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

  • 0582GeneralS&S Dpotential for harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0584GeneralS&S Dpotential for harm

    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.

  • 0600GeneralS&S Dpotential for harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

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

  • 0607GeneralS&S Epotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0622GeneralS&S Dpotential for harm

    F622 - Transfer and discharge-

    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.

  • 0637GeneralS&S Dpotential for harm

    F637 - Within 14 days after the facility determines, or should have determined,

    Assess the resident when there is a significant change in condition

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0655GeneralS&S Epotential for harm

    F655 - Comprehensive Person-Centered Care Planning

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

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

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

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

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

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0661GeneralS&S Dpotential for harm

    F661 - Quality of life

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

  • 0676GeneralS&S Epotential for harm

    F676 - Based on the comprehensive assessment of a resident and consistent with

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686SeriousS&S Gactual harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    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.

  • 0689SeriousS&S Kimmediate jeopardy

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0710GeneralS&S Dpotential for harm

    F710 - Physician Services

    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

  • 0725GeneralS&S Dpotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0727GeneralS&S Epotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0805SeriousS&S Kimmediate jeopardy

    F805 - Food and drink

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

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

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

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

  • 0868GeneralS&S Epotential for harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0883GeneralS&S Dpotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0886GeneralS&S Epotential for harm

    Perform COVID19 testing on residents and staff.

  • 0887GeneralS&S Epotential for harm

    F887 - Infection control

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

  • 0943GeneralS&S Epotential for harm

    F943 - Abuse, neglect, and exploitation

    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  • 0640GeneralS&S Dpotential for harm

    F640 - Automated data processing requirement-

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0660GeneralS&S Dpotential for harm

    F660 - Quality of life

    Plan the resident's discharge to meet the resident's goals and needs.

FAQ · About this visit

Common questions about this visit

What happened during the May 4, 2023 survey of Embassy Rehab and Care Center?

This was a inspection survey of Embassy Rehab and Care Center on May 4, 2023. The surveyor cited 36 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Embassy Rehab and Care Center on May 4, 2023?

Yes, 36 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to easily view the nursing home's survey results and communicate with advocate agencies."

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.

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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.