CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Santa Anita Convalescent Hospital
A list of the most recent deficiencies for Santa Anita Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Santa Anita Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-26 | 2024-09-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-16 | 2024-09-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-16 | 2024-09-06 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-08-16 | 2024-09-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-16 | 2024-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-16 | 2024-09-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-16 | 2024-09-06 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-14 | 2024-08-26 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-08-09 | 2024-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-09 | 2024-08-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-27 | 2024-08-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-27 | 2024-08-23 | Y |
| 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. | Health | 2024-07-27 | 2024-08-23 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-31 | 2024-06-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-25 | 2024-06-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-25 | 2024-06-23 | N |
| 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. | Health | 2024-05-25 | 2024-06-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-25 | 2024-06-23 | N |
| 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. | Health | 2024-05-25 | 2024-06-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-25 | 2024-06-23 | N |
| 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. | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-25 | 2024-06-23 | N |
| 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. | Health | 2024-05-25 | 2024-06-23 | N |
| 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. | Health | 2024-05-25 | 2024-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-25 | 2024-06-23 | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-25 | 2024-06-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-05-25 | 2024-06-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-25 | 2024-06-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-25 | 2024-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-25 | 2024-06-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-04 | 2024-05-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-10 | 2024-05-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-23 | 2024-05-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-23 | 2024-05-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-19 | 2024-05-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-14 | 2024-05-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-04-14 | 2024-05-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-25 | 2024-05-08 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-03-13 | 2024-03-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-06 | 2024-03-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-06 | 2024-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-13 | 2024-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-05 | 2024-03-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-27 | 2024-02-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-09 | 2024-02-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-08 | 2024-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-08 | 2024-01-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-27 | 2024-01-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-06 | 2024-01-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-15 | 2023-12-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | 2023-12-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-15 | 2023-12-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-13 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-06 | 2023-10-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-25 | 2023-10-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-01 | 2023-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-01 | 2023-08-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-01 | 2023-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-07-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-17 | 2023-06-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-17 | 2023-06-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-17 | 2023-06-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-17 | 2023-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-17 | 2023-06-17 | N |
| Post nurse staffing information every day. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-17 | N |
| 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. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-17 | 2023-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-17 | 2023-06-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-05-17 | 2023-06-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-17 | 2023-06-17 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-07 | 2023-05-24 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-07 | 2023-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-24 | 2023-05-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-19 | 2023-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-07 | 2023-05-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-07 | 2023-05-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-07 | 2023-05-09 | Y |
| 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. | Health | 2023-03-30 | 2023-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-22 | 2023-04-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-22 | 2023-04-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-10 | 2023-04-24 | Y |
| 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. | Health | 2023-03-17 | 2023-04-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-03-17 | 2023-04-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-09 | 2023-04-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-04-04 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-03-08 | 2023-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-07 | 2023-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-19 | 2023-02-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-08 | 2023-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-27 | 2023-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-06 | 2023-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-15 | 2022-11-30 | Y |
| Report COVID19 data to residents and families. | Health | 2022-10-15 | 2022-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-08 | 2022-11-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-28 | 2022-10-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-28 | 2022-10-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-23 | 2022-09-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-05 | 2022-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-22 | 2022-07-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-12 | 2022-06-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-14 | 2022-05-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-12 | 2022-04-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-15 | 2022-04-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-11 | 2022-03-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-07 | 2022-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-26 | 2019-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-10-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Post nurse staffing information every day. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-10-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-26 | 2019-10-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-26 | 2019-10-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-27 | 2019-10-22 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-27 | 2019-10-22 | N |
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