MULTY MEDICAL SKILLED NURSING FACILITY

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

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

Administration Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024

Have a Compliance and Ethics Program.

Administration Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Keep all essential equipment working safely.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected September 25, 2024

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 9, 2024

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 20, 2024

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 25, 2024

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 20, 2024

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 20, 2024

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 4, 2024

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 26, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 29, 2024

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 29, 2024

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide appropriate foot care.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 14, 2024

Provide appropriate care/assistance for a resident with a prosthesis.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide routine and 24-hour emergency dental care for each resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 4, 2024

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 25, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide immediate access to any resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Give residents a notice of rights, rules, services and charges.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

The resident has the right to receive notices in a format and a language he or she understands.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 3, 2024

Provide information about how to apply for and use Medicare and Medicaid benefits.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Prepare residents for a safe transfer or discharge from the nursing home.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2024