Care Citations

BURGH CARE CENTER

909 WEST STREET, PITTSBURGH, PA, 15221 · 4127233662

What CMS has flagged

  • CMS status on record: SFF Candidate.

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
4 / 5
Certified beds
126
Ownership type
For profit - Corporation
Chain
WECARE CENTERS

Inspection findings on record (120)

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

— Nutrition and Dietary Deficiencies

Tag 0801 · scope/severity F · potential for more than minimal harm

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · 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 .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0605 · scope/severity E · 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 Rights Deficiencies

Tag 0628 · scope/severity E · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

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 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 .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity E · 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 .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity E · 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 .

— 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 .

— Administration Deficiencies

Tag 0941 · scope/severity E · potential for more than minimal harm

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0942 · scope/severity E · potential for more than minimal harm

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0943 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0944 · scope/severity E · potential for more than minimal harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0945 · scope/severity E · potential for more than minimal harm

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Recorded as corrected on .

— Administration Deficiencies

Tag 0946 · scope/severity E · potential for more than minimal harm

Provide training in compliance and ethics.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0947 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0949 · scope/severity E · potential for more than minimal harm

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity D · potential for more than minimal harm

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

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 .

— Resident Rights Deficiencies

Tag 0620 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

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

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 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0691 · scope/severity D · potential for more than minimal harm

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

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 .

— 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 .

— 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 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 .

— Infection Control Deficiencies

Tag 0887 · scope/severity D · 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 .

— Environmental Deficiencies

Tag 0908 · scope/severity D · potential for more than minimal harm

Keep all essential equipment working safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0575 · scope/severity C · potential for minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0577 · scope/severity C · potential for minimal harm

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

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0579 · scope/severity C · potential for minimal harm

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

Recorded as corrected on .

— 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 .

— 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 .

— Administration Deficiencies

Tag 0840 · scope/severity D · potential for more than minimal harm

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Recorded as corrected on .

— Administration Deficiencies

Tag 0844 · scope/severity D · potential for more than minimal harm

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0917 · scope/severity D · potential for more than minimal harm

Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity G · actual harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity J · immediate jeopardy

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

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 .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity F · 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 0812 · scope/severity F · 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 F · 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 F · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0882 · scope/severity F · potential for more than minimal harm

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0944 · scope/severity F · potential for more than minimal harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity E · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0680 · scope/severity E · potential for more than minimal harm

Ensure the activities program is directed by a qualified professional.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

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

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

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity E · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity E · 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 .

— 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 .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity D · potential for more than minimal harm

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

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 Rights Deficiencies

Tag 0620 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0637 · scope/severity D · potential for more than minimal harm

Assess the resident when there is a significant change in condition

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 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 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 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity D · potential for more than minimal harm

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

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 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 0699 · scope/severity D · potential for more than minimal harm

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

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 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 .

— 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 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 0809 · scope/severity D · potential for more than minimal harm

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Recorded as corrected on .

— Administration Deficiencies

Tag 0840 · scope/severity D · potential for more than minimal harm

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity D · potential for more than minimal harm

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

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity J · immediate jeopardy

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity F · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0841 · scope/severity F · potential for more than minimal harm

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

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 .

— 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 .

— Nursing and Physician Services Deficiencies

Tag 0712 · scope/severity D · potential for more than minimal harm

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0572 · scope/severity D · potential for more than minimal harm

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

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 .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

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 .

— 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 .

— 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 .

— 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 .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity D · potential for more than minimal harm

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

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 0689 · scope/severity K · immediate jeopardy

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

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity F · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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 F · 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 .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity E · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

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 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 .

— Quality of Life and Care Deficiencies

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

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

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity E · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity E · potential for more than minimal harm

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

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 0882 · scope/severity E · potential for more than minimal harm

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

Recorded as corrected on .

— 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 .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity D · potential for more than minimal harm

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

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 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 0688 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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 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 .

— 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 .

— 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 .

— 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 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 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 .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 395883