Based on record reviews and staff interviews, the facility failed to implement their Admissions Policy and Procedure and verify the identity of a cognitively impaired resident when he was admitted to the facility with paperwork from the discharging skilled nursing facility for Person #2 (potential new admission with same first and last name as Resident #1). As a result, Resident #1, who did not have a diagnosis of diabetes, was administered 3 doses of long-acting insulin, and experienced 3 three low blood sugar levels before the insulin was discontinued. In addition, Resident #1 received an anticoagulant, aspirin, a diuretic, and a medication used to treat hypothyroidism from 07/17/23 until 09/15/23 prescribed for Person #2. …
F620
Resident Rights Deficiencies
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F620 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F620 finding.
The harm level
How severely F620 is cited
0.8% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J10.8% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D8563.9% | E2015.0% | F1813.5% |
| No harm, potential for minimal | A— | B21.5% | C75.3% |
In the surveyor’s words
What an F620 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 interview and record review, the facility failed to establish and implement an admissions policy that ensured residents were not requested or required to waive potential facility liability for losses of personal property upon admission for 2 of 2 residents (Resident #2 and Resident #3) reviewed for admissions policy. The facility's admission policy had a statement waiving the facility from liability for the security of residents retained personal property for Residents #2 and #3. This failure could place the residents at risk of not having the right to use personal possessions and financial loss. …
Based on record review and interview, it was determined that the facility admission agreement failed to include special characteristics and service limitations related to a kosher diet, and requested residents waive their rights as well as waive potential facility liability for personal property losses. The findings include:On 2/19/26 at 1:51 PM a review of the admission packet revealed the admission Agreement. A review of this document failed to reveal information regarding the facility's kosher diet. In addition, the document requires the resident and sponsor agree to not hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse.Further review revealed a Risk Acknowledgement. …
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