Inspection visit
Inspection
Citations
43 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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
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.
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.
F551 - In the case of a resident who has not been adjudged incompetent by the state
Give the resident's representative the ability to exercise the resident's rights.
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.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F849 - Hospice services
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.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
F791 - Dental Services
Provide or obtain dental services for each resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F837 - Governing body
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
F838 - Facility assessment
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0374GeneralS&S Dpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0004GeneralS&S Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Epotential for harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Dpotential for harm
Establish roles under a Waiver declared by secretary.
- 0036GeneralS&S Epotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Epotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Epotential for harm
Conduct testing and exercise requirements.
- 0300GeneralS&S Epotential for harm
Meet other general requirements that are deficient.
- 0311GeneralS&S Dpotential for harm
Have an enclosure around a vertical opening shaft.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the February 20, 2020 survey of AFFINITY HEALTHCARE?
This was a inspection survey of AFFINITY HEALTHCARE on February 20, 2020. The surveyor cited 43 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AFFINITY HEALTHCARE on February 20, 2020?
Yes, 43 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
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.