Inspection visit
Inspection
Citations
22 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.
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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F693 - Assisted nutrition and hydration
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F728 - Requirement for facility hiring and use of nurse aides-
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F946 - Compliance and ethics
Provide training in compliance and ethics.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
FAQ · About this visit
Common questions about this visit
What happened during the August 23, 2024 survey of ELMORA HILLS HEALTH & REHABILITATION CENTER?
This was a inspection survey of ELMORA HILLS HEALTH & REHABILITATION CENTER on August 23, 2024. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELMORA HILLS HEALTH & REHABILITATION CENTER on August 23, 2024?
Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
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.