Inspection visit
Inspection
Citations
41 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F570 - Assurance of financial security
Assure the security of all personal funds of residents deposited with the facility.
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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
F843 - Transfer agreement
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F922 - Establish procedures to ensure that water is available to essential areas
Have enough backup water supply for essential areas of the nursing home.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0271GeneralS&S Fpotential for harm
Have exits that are accessible at all times.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0374GeneralS&S Fpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0500GeneralS&S Fpotential for harm
Meet other general requirements that are deficient.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F921 - Other Environmental Conditions
Ensure that testing and maintenance of electrical equipment is performed.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
FAQ · About this visit
Common questions about this visit
What happened during the December 5, 2024 survey of THE PINES AT MEDFORD?
This was a inspection survey of THE PINES AT MEDFORD on December 5, 2024. The surveyor cited 41 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE PINES AT MEDFORD on December 5, 2024?
Yes, 41 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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.