Bella Terra St George (Black Rock Health and Rehab

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident’s ability to function.

Rule F0605. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jan 23, 2026.

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: Jan 23, 2026.

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

Rule F0600. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Rule F0603. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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: Jan 7, 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: Jan 7, 2025.

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. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. H: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. H: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Rule F0740. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Rule F0802. G: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0835. H: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0867. H: actual harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Rule F0553. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure residents have reasonable access to and privacy in their use of communication methods.

Rule F0576. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. From a complaint. Correction date, as CMS recorded it: Jan 7, 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. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 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. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Protect each resident from the wrongful use of the resident’s belongings or money.

Rule F0602. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0607. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0609. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Prepare residents for a safe transfer or discharge from the nursing home.

Rule F0624. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Rule F0625. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide doctor’s orders for the resident’s immediate care at the time the resident was admitted.

Rule F0635. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Rule F0640. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0655. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 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. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Rule F0676. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide activities to meet all resident’s needs.

Rule F0679. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0692. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Post nurse staffing information every day.

Rule F0732. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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: Jan 7, 2025.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 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. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide timely, quality laboratory services/tests to meet the needs of residents.

Rule F0770. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Keep complete, dated laboratory records in the resident’s record.

Rule F0775. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Rule F0800. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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.

Rule F0803. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Rule F0804. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Rule F0806. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Rule F0807. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Rule F0808. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Rule F0810. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 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. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0842. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Rule F0849. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Implement a program that monitors antibiotic use.

Rule F0881. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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

Rule F0883. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

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. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.

Make sure that a working call system is available in each resident’s bathroom and bathing area.

Rule F0919. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 7, 2025.