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DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF DEFICIENCIES · CMS-2567
ID
SUMMARY OF DEFICIENCY
PLAN OF CORRECTION
F-725
D
§483.25 QUALITY OF CARE
Based on observation and staff interview, the facility failed to ensure resident received adequate hydration for 1 of 12 residents reviewed (R#1)...
The facility will ensure all residents receive adequate hydration per care plan. The DON will...
F-880
E
INFECTION PREVENTION
Staff observed without appropriate PPE during care delivery for R#2 and R#4...
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F-725 · Plan of Correction
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Correction
Cause
Prevention
Date

1. Correction: The facility immediately assessed R#1 and ensured hydration needs were met per physician orders and care plan. All residents on the unit received hydration checks within 24 hours.

2. Cause: Investigation revealed the care plan lacked specific fluid intake targets. The morning shift did not document fluid consumption in the EHR.

3. Prevention: The DON will audit hydration documentation for all high-risk residents weekly × 4 weeks, then monthly × 2 months.

4. Date: 03/15/2026

Action Items
Hydration audit — all residents
Care plan update — R#1
Staff education session
Policy revision — fluid monitoring
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CMS-2567 · Page 1 of 3
F725
The facility will ensure all residents receive adequate hydration. Staff will document fluid intake every shift...
2 of 3 deficiencies matched
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Generating four-element POC...
Deficiency pasted
F-880: Staff observed without appropriate PPE during care delivery for R#2. CNA failed to don gloves prior to wound care procedure...
Correction: Immediate corrective action: CNA re-educated on PPE protocols. R#2 assessed for adverse outcomes. No harm identified.
Cause: Root cause: PPE supply station was depleted on 2-North wing. Charge nurse failed to restock per protocol.
Prevention: DON will audit PPE station compliance daily × 30 days...
Date:
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F-725
Quality of Care
Scope: D · Pattern
📋 CFR Citation
42 CFR §483.25
📖 SOM Guidance
F725 applies to residents who need assistance with activities of daily living — ensuring each resident maintains the highest practicable...
Read full guidance →
⚡ Common Triggers
HydrationRepositioningOral careSkin integrity
IJ
K
L
M
N
Action Plan Tracker
F-725 · 3 of 5 complete
60%
Hydration audit — all residents03/08✓ Done
Care plan revision — R#103/08✓ Done
Staff education — AM shift03/10● Active
Policy update — fluid monitoring03/12● Active
Audit #2 — high-risk residents03/22○ Soon

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51 facilities · 5 states
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Portland, OR
3 open
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Seattle, WA
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Boise, ID
7 open ⚠️
Meadow View Post-Acute
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2 open
Harbor Heights SNF
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