Ahmc Seton Medical Center

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.

Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

Assess the resident when there is a significant change in condition

Rule F0637. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 30, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 30, 2025.

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

Rule F0656. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

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

Rule F0692. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

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.

Rule F0801. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 30, 2025.

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

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 30, 2025.

Have a plan that describes the process for conducting QAPI and QAA activities.

Rule F0865. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

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

Rule F0867. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

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

Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 23, 2026.

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.

Rule F0584. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Sep 30, 2025.

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

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 23, 2026.

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

Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jun 9, 2025.

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

Rule F0628. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 20, 2025.

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.

Rule F0585. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 6, 2025.

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

Rule F0686. G: actual harm. Correction date, as CMS recorded it: Apr 20, 2024.

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.

Rule F0758. G: actual harm. Correction date, as CMS recorded it: Mar 14, 2024.

Honor the resident’s right to be treated with respect and dignity and to retain and use personal possessions.

Rule F0557. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 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.

Rule F0584. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

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.

Rule F0585. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

Ensure each resident receives an accurate assessment.

Rule F0641. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

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

Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

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.

Rule F0688. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

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

Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 27, 2024.

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

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 21, 2024.

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

Rule F0842. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

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

Rule F0883. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 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.

Rule F0887. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

Keep all essential equipment working safely.

Rule F0908. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Rule F0920. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.

Put firmly secured handrails on each side of hallways.

Rule F0924. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 20, 2024.