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Inspection visit

Inspection

CORNELL HALL CARE & REHABILITATION CENTERCMS #31510429 citations on this visit
29 citations recorded

Citations

29 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 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.

  • 0640GeneralS&S Dpotential for harm

    F640 - Automated data processing requirement-

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

  • 0641GeneralS&S Cno actual harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    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.

  • 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.

  • 0730GeneralS&S Dpotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0732GeneralS&S Dpotential for harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0756GeneralS&S Epotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758GeneralS&S Dpotential 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.

  • 0804GeneralS&S Dpotential for harm

    F804 - Food and drink

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

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0882GeneralS&S Dpotential for harm

    F882 - Infection preventionist

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0947GeneralS&S Dpotential for harm

    F947 - Training Requirements

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  • 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.

  • 0725GeneralS&S Fpotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0321GeneralS&S Dpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0345GeneralS&S Epotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353GeneralS&S Epotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0355GeneralS&S Epotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0692SeriousS&S Gactual harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0851GeneralS&S Fpotential for harm

    F851 - Mandatory submission of staffing information based on payroll data in a

    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  • 0868GeneralS&S Dpotential for harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 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.

  • 0363GeneralS&S Epotential for harm

    Install corridor and hallway doors that block smoke.

  • 0374GeneralS&S Dpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0918GeneralS&S Dpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

FAQ · About this visit

Common questions about this visit

What happened during the January 24, 2024 survey of CORNELL HALL CARE & REHABILITATION CENTER?

This was a inspection survey of CORNELL HALL CARE & REHABILITATION CENTER on January 24, 2024. The surveyor cited 29 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CORNELL HALL CARE & REHABILITATION CENTER on January 24, 2024?

Yes, 29 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.