Passavant Retirement and Healt

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

Rule F0684. G: actual harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0628. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0686. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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: Apr 21, 2026.

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

Rule F0691. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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.

Rule F0761. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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 21, 2026.

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

Rule F0941. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0942. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0944. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0945. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

Provide training in compliance and ethics.

Rule F0946. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0947. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0949. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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.

Rule F0575. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Apr 21, 2026.

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

Rule F0600. G: actual harm. From a complaint. Correction date, as CMS recorded it: Oct 24, 2025.

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: Oct 24, 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: Aug 24, 2025.

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

Rule F0554. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 1, 2025.

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 1, 2025.

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. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 1, 2025.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 1, 2025.

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

Rule F0847. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 1, 2025.

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: Apr 1, 2025.

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. From a complaint. Correction date, as CMS recorded it: Feb 27, 2025.

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. From a complaint. Correction date, as CMS recorded it: Oct 29, 2024.

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

Rule F0600. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 3, 2024.

Keep residents’ personal and medical records private and confidential.

Rule F0583. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 22, 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: Apr 22, 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. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 22, 2024.

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

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 22, 2024.

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

Rule F0699. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 22, 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. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 22, 2024.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 22, 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: Apr 22, 2024.