Charlene Manor Extended Care Facility

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. G: actual harm. Correction date, as CMS recorded it: Mar 13, 2026.

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. From a complaint. Correction date, as CMS recorded it: May 30, 2025.

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. From a complaint. Correction date, as CMS recorded it: Apr 11, 2025.

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

Rule F0686. G: actual harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0580. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0582. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0604. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 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.

Rule F0622. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0655. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Rule F0677. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Provide appropriate foot care.

Rule F0687. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0690. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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: Dec 26, 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.

Rule F0700. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0725. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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.

Rule F0726. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

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

Rule F0757. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Ensure that residents are free from significant medication errors.

Rule F0760. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Provide or obtain dental services for each resident.

Rule F0791. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Dec 26, 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: Dec 26, 2024.

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: Dec 26, 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: Dec 26, 2024.

Assess the resident when there is a significant change in condition

Rule F0637. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Ensure each resident receives an accurate assessment.

Rule F0641. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Dec 26, 2024.

Post nurse staffing information every day.

Rule F0732. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Dec 26, 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. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 10, 2024.

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. From a complaint. Correction date, as CMS recorded it: Aug 10, 2024.

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

Rule F0607. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 27, 2024.

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

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 27, 2024.

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

Rule F0943. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 27, 2024.