Based on observation, record review, and interview during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure the resident's ability to safely self-administer medications was clinically appropriate for 5 of 5 residents (Residents #21, #64, #72, #207, and #239) reviewed. Specifically, Residents #21, #64, #72, and #207 had medications that were left in their room, with some being unidentified. Resident #239 was not observed by nursing staff to ensure their controlled substance, which was used to treat narcotic addiction, was taken as prescribed. There was no documented evidence these residents were assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication. …
F554
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F554 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F554 finding.
The harm level
How severely F554 is cited
0.1% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K10.0% | L— |
| Actual harm | G20.1% | H— | I— |
| No harm, potential for more than minimal | D2,22193.2% | E1466.1% | F60.3% |
| No harm, potential for minimal | A— | B80.3% | C— |
In the surveyor’s words
What an F554 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure the interdisciplinary team determined a resident's ability to self-administer medications was clinically appropriate for one (1) of one (1) resident (Resident #147) reviewed. Specifically, Resident #147 had expired and/or discontinued medications and used insulin needles in their room.Findings include: The facility policy Self- Administration of Medications dated 01/2025, documented residents had the right to self-administer medications if the interdisciplinary team determined that it is clinically appropriate for the resident to do so. Self-administered medications must be stored in a safe and secure place, which is not accessible by another resident. …
Waterview Heights Rehabilitation and Nursing Cente · New York
Based on observation, interview and document review, the facility failed to ensure medications were administered safely for 1 of 2 residents (R139) who had medications left at the bedside and had been assessed as not safe to self administer those medications.Findings Include:R139's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R139 had moderate cognitive impairment with diagnoses which included arthritis, adjustment disorder with depressed mood and chronic pain. …
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of six sampled residents (Residents 2 and 4) were assessed for safe self-administration of medications. * Resident 2 was observed with a full and uncovered 16 ounces tub of zinc oxide (a medicated cream used as a protective barrier for the affected skin areas) inside his restroom. * Resident 4 was observed with Halls cough drops on the bedside table. These failures had the potential for Residents 2 and 4 to administer the medications inaccurately and may negatively impact the health and safety of the residents.Findings: Review of the facility's P&P titled Resident Self-Administration of Medication revised 12/19/22, showed a resident may only self-administer medications after… …
By state — 2025
Where F554 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Georgia4.24× · 42 citations
- Minnesota3.29× · 48 citations
- Indiana2.53× · 51 citations
- Florida1.44× · 25 citations
- Pennsylvania1.12× · 42 citations
- California0.92× · 82 citations
- Illinois0.87× · 33 citations
Co-occurrence
Cited alongside F554
Of the 2025 surveys that cited F554, these tags appeared in the same inspection more often than chance would predict.
- F69813.7% of F554 surveys · 4.4× chance
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- F8067.2% of F554 surveys · 4.4× chance
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F7006.5% of F554 surveys · 4.0× chance
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- F8817.8% of F554 surveys · 3.9× chance
Implement a program that monitors antibiotic use.
- F75917.1% of F554 surveys · 3.8× chance
Ensure medication error rates are not 5 percent or greater.
Cited in the same inspection, not caused by one another.
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