Care Citations

ADVANCED REHAB CENTER OF TUSTIN

2210 E. FIRST STREET, SANTA ANA, CA, 92705 · 7145477091

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
3 / 5
Certified beds
99
Ownership type
For profit - Corporation
Chain
ABRAHAM BAK & MENACHEM GASTWIRTH

Inspection findings on record (124)

Quoted exactly as CMS published them. We do not rewrite findings.

— Resident Rights Deficiencies

Tag 0584 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0578 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity E · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity E · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0887 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0558 · scope/severity D · potential for more than minimal harm

Reasonably accommodate the needs and preferences of each resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0605 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0685 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0694 · scope/severity D · potential for more than minimal harm

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0770 · scope/severity D · potential for more than minimal harm

Provide timely, quality laboratory services/tests to meet the needs of residents.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity D · potential for more than minimal harm

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0806 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0921 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0583 · scope/severity B · potential for minimal harm

Keep residents' personal and medical records private and confidential.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0636 · scope/severity B · potential for minimal harm

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity B · potential for minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity B · potential for minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity B · potential for minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0660 · scope/severity D · potential for more than minimal harm

Plan the resident's discharge to meet the resident's goals and needs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0694 · scope/severity D · potential for more than minimal harm

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity D · potential for more than minimal harm

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0805 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0813 · scope/severity D · potential for more than minimal harm

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity D · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0558 · scope/severity B · potential for minimal harm

Reasonably accommodate the needs and preferences of each resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0582 · scope/severity B · potential for minimal harm

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

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0640 · scope/severity B · potential for minimal harm

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

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity B · potential for minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0622 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0576 · scope/severity B · potential for minimal harm

Ensure residents have reasonable access to and privacy in their use of communication methods.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity B · potential for minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity B · potential for minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity G · actual harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity B · potential for minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity D · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity B · potential for minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity B · potential for minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity B · potential for minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity B · potential for minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity B · potential for minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity G · actual harm

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

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0558 · scope/severity D · potential for more than minimal harm

Reasonably accommodate the needs and preferences of each resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0604 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0693 · scope/severity D · potential for more than minimal harm

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0700 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0744 · scope/severity D · potential for more than minimal harm

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity D · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0802 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0806 · scope/severity D · potential for more than minimal harm

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0813 · scope/severity D · potential for more than minimal harm

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0847 · scope/severity D · potential for more than minimal harm

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity D · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Environmental Deficiencies

Tag 0909 · scope/severity D · potential for more than minimal harm

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0583 · scope/severity B · potential for minimal harm

Keep residents' personal and medical records private and confidential.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity B · potential for minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity B · potential for minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0814 · scope/severity B · potential for minimal harm

Dispose of garbage and refuse properly.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 055330