Southwestern Manor Nursing and Rehabilitation

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. From a complaint. Correction date, as CMS recorded it: Aug 5, 2026.

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: Apr 7, 2026.

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: Apr 7, 2026.

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: Apr 7, 2026.

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

Rule F0698. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Apr 7, 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 7, 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 7, 2026.

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

Rule F0577. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Apr 7, 2026.

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

Rule F0579. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Apr 7, 2026.

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: Mar 4, 2025.

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: Mar 4, 2025.

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: Mar 4, 2025.

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: Mar 4, 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: Mar 4, 2025.

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: Mar 4, 2025.

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

Rule F0943. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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: Mar 4, 2025.

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. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Rule F0848. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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

Rule F0941. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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

Rule F0942. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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

Rule F0944. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Provide training in compliance and ethics.

Rule F0946. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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

Rule F0949. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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: Aug 6, 2024.

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

Rule F0684. H: actual harm. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

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

Rule F0686. G: actual harm. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

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: Aug 6, 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. From a complaint. Correction date, as CMS recorded it: Aug 6, 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. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

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

Rule F0744. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Rule F0745. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

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. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Rule F0940. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 6, 2024.

Keep residents’ personal and medical records private and confidential.

Rule F0583. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 2, 2024.

Honor the resident’s right to organize and participate in resident/family groups in the facility.

Rule F0565. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

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. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 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: Feb 6, 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. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 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: Feb 6, 2024.

Ensure the activities program is directed by a qualified professional.

Rule F0680. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

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

Rule F0684. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

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

Rule F0686. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

Obtain a doctor’s order to admit a resident and ensure the resident is under a doctor’s care.

Rule F0710. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 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 6, 2024.

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.

Rule F0809. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

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.

Rule F0838. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Feb 6, 2024.

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

Rule F0944. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Feb 6, 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. From a complaint. Correction date, as CMS recorded it: Feb 6, 2024.