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Inspection visit

Inspection

ACHIEVE REHAB AND NURSING FACILITYCMS #3354499 citations on this visit
9 citations recorded

Citations

9 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.

  • 0225GeneralS&S Epotential for harm

    Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  • 0281GeneralS&S Epotential for harm

    Install proper backup exit lighting.

  • 0353GeneralS&S Bno actual harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0623GeneralS&S Dpotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 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 Dpotential 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.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

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

  • 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.

  • 0756GeneralS&S Dpotential for harm

    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.

FAQ · About this visit

Common questions about this visit

What happened during the March 28, 2019 survey of ACHIEVE REHAB AND NURSING FACILITY?

This was a inspection survey of ACHIEVE REHAB AND NURSING FACILITY on March 28, 2019. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ACHIEVE REHAB AND NURSING FACILITY on March 28, 2019?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have stairways and smokeproof enclosures used as exits that meet safety requirements."

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.