CCN 065175

Kiowa Hills Rehabilitation and Nursing, LLC

924 W KIOWA ST, Colorado Springs, CO 80905 · El Paso County

Phone: (719) 636-5221
Ownership: For profit - Limited Liability company
Certified beds: 83
Residents per day: 78.1
Health citations: 66
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 1 · short-stay —.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

CMS has turned on the abuse icon. The September 2026 Technical Users' Guide applies that icon for abuse tags F600, F602, or F603: a citation at scope and severity G or higher on the most recent standard survey or on a complaint or focused infection-control survey in the past 12 months, or a repeat citation at D or higher across the recent windows described in the guide. While the icon is on, the health inspection rating is capped at two stars.

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.52; 2.21; 2.32
LPN/LVN: 0.77; 0.68; 0.86
Registered nurse: 0.46; 0.82; 0.69
Total nurse staff: 2.75; 3.72; 3.86
Weekend total: 2.43; 3.29; 3.42
Weekend RN: 0.31; 0.60; 0.48

Adjusted total nurse hours: 2.55. Adjusted RN hours: 0.43. Case-mix total: 4.13. Case-mix index: 1.509.

Total nursing staff turnover: 54.0%. RN turnover: 57.1%. Administrators who left: —.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: January 16, 2025. Health deficiencies counted in cycle 1: 16. Cycle 1 total health score: 124.

Cycle 2 standard survey: December 7, 2023. Cycle 2/3 health deficiencies: 28. Total weighted health survey score: 153.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 66 citations for this home, including 0 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

July 22, 2026

2 citations

Tag	What CMS cited	Scope and severity	Status
F600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has plan of correction · August 17, 2026
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Past Non-Compliance · June 10, 2026

December 10, 2025

1 citation

Tag	What CMS cited	Scope and severity	Status
F561	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Complaint survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 10, 2026

August 27, 2025

7 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025
F565	Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025
F803	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025
F804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025
F600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025
F677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 6, 2025

January 16, 2025

13 citations

Tag	What CMS cited	Scope and severity	Status
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · February 14, 2025
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F553	Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F584	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. Resident Rights Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F680	Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F550	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F561	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F585	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. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025
F849	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. Administration Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 14, 2025

December 7, 2023

17 citations

Tag	What CMS cited	Scope and severity	Status
F804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F867	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Complaint survey · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F565	Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F584	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. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F726	Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F760	Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F838	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. Administration Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F923	Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F925	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Complaint survey · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F742	Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F849	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. Administration Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 28, 2024

September 18, 2023

4 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Complaint survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 12, 2023
F925	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Complaint survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 12, 2023
F550	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Complaint survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 21, 2023
F677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 12, 2023

August 25, 2022

22 citations

Tag	What CMS cited	Scope and severity	Status
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F886	Perform COVID19 testing on residents and staff. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F888	Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F553	Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F563	Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F584	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. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F688	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. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F554	Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F659	Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F687	Provide appropriate foot care. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F690	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F691	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F849	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. Administration Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F921	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: The Charly Bello Family, the Maze Family, the Swain Family, & Walter Myers (20 facilities). Chain average overall rating: 1.7.
Legal business name: Kiowa Hills Rehabilitation and Nursing LLC.
First approved for Medicare and Medicaid services: July 1, 1981.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Kiowa Hills Rehabilitation and Nursing, LLC?

Kiowa Hills Rehabilitation and Nursing, LLC has an overall rating of 1 out of 5. The health inspection rating is 1, staffing is 1, and the quality measure rating is 1.

How many health citations does CMS list for Kiowa Hills Rehabilitation and Nursing, LLC?

The Health Deficiencies file lists 66 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 1 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Kiowa Hills Rehabilitation and Nursing, LLC?

CMS reports 2.75 total nurse hours per resident per day, including 0.46 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

August 25, 2022

22 citations

Tag	What CMS cited	Scope and severity	Status
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F886	Perform COVID19 testing on residents and staff. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F888	Ensure staff are vaccinated for COVID-19 Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F553	Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F563	Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F584	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. Resident Rights Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F688	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. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F554	Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F659	Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F687	Provide appropriate foot care. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F690	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F691	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F849	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. Administration Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022
F921	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2022