Health inspection·June 15, 2023

Citations

17 citations recorded^*CMS

• 0585GeneralS&S Epotential for harm

  F585 - Grievances

  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.

• 0607GeneralS&S Epotential for harm

  F607 - The facility must develop and implement written policies and procedures that:

  Develop and implement policies and procedures to prevent abuse, neglect, and theft.

• 0609GeneralS&S Epotential for harm

  F609 - The facility must develop and implement written policies and procedures that:

  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

• 0610GeneralS&S Epotential for harm

  F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

  Respond appropriately to all alleged violations.

• 0623GeneralS&S Cno actual 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.

• 0625GeneralS&S Cno actual harm

  F625 - Transfer and discharge-

  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

• 0656GeneralS&S Epotential 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.

• 0689GeneralS&S Epotential for harm

  F689 - Accidents

  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• 0695GeneralS&S Dpotential for harm

  F695 - Respiratory care, including tracheostomy care and tracheal suctioning

  Provide safe and appropriate respiratory care for a resident when needed.

• 0758GeneralS&S Epotential for harm

  F758 - Medication Errors

  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.

• 0761GeneralS&S Fpotential for harm

  F761 - Labeling of Drugs and Biologicals

  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.

• 0804GeneralS&S Epotential for harm

  F804 - Food and drink

  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

• 0812GeneralS&S Fpotential for harm

  F812 - Food safety requirements

  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

• 0849GeneralS&S Dpotential for harm

  F849 - Hospice services

  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.

• 0867GeneralS&S Fpotential for harm

  F867 - Program feedback, data systems and monitoring

  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

• 0880GeneralS&S Epotential for harm

  F880 - Infection Control

  Provide and implement an infection prevention and control program.

• 0943GeneralS&S Dpotential for harm

  F943 - Abuse, neglect, and exploitation

  Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.