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Deficiency Records for Mirage Post Acute

A list of the most recent deficiencies for Mirage Post Acute. 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 Mirage Post Acute. 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?
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2024-08-08 2024-08-20 Y
Ensure that residents are free from significant medication errors. Health 2024-08-08 2024-08-20 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-07-11 2024-07-17 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-05-06 2024-05-24 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-05-06 2024-05-24 Y
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Health 2024-05-06 2024-05-24 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-05-01 2024-05-10 Y
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 2024-05-01 2024-05-10 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-04-16 2024-04-25 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 2024-03-18 2024-04-04 Y
Honor each resident's preferences, choices, values and beliefs. Health 2024-03-18 2024-04-04 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-18 2024-04-04 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-03-18 2024-04-04 Y
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 2024-03-18 2024-04-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-18 2024-04-04 Y
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2024-03-18 2024-04-04 Y
Provide and implement an infection prevention and control program. Health 2024-03-18 2024-04-04 Y
Keep all essential equipment working safely. Health 2024-03-18 2024-04-04 Y
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2024-01-30 2024-02-29 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2024-01-30 2024-02-29 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-01-30 2024-02-29 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-01-30 2024-02-29 N
Provide properly protected cooking facilities. Fire Safety 2024-01-30 2024-02-29 N
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Fire Safety 2024-01-30 2024-02-29 N
Install an approved automatic sprinkler system. Fire Safety 2024-01-30 2024-02-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-01-30 2024-02-29 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2024-01-30 2024-02-29 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-01-30 2024-02-29 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-01-30 2024-02-29 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-01-30 2024-02-29 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-01-30 2024-02-29 N
Have restrictions on the use of portable space heaters. Fire Safety 2024-01-30 2024-02-29 N
Have power receptacles that are properly grounded. Fire Safety 2024-01-30 2024-02-29 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-01-30 2024-02-29 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-01-30 2024-02-29 N
Have proper medical gas storage and administration areas. Fire Safety 2024-01-30 2024-02-29 N
Ensure that sources of ignition are removed from patients receiving respiratory therapy. Fire Safety 2024-01-30 2024-02-29 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2024-01-26 2024-02-23 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2024-01-26 2024-02-23 N
Reasonably accommodate the needs and preferences of each resident. Health 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2024-01-26 2024-02-23 N
Respond appropriately to all alleged violations. Health 2024-01-26 2024-02-23 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-01-26 2024-02-23 N
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 2024-01-26 2024-02-23 N
Assess the resident when there is a significant change in condition Health 2024-01-26 2024-02-23 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2024-01-26 2024-02-23 N
Ensure each resident receives an accurate assessment. Health 2024-01-26 2024-02-23 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2024-01-26 2024-02-23 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-01-26 2024-02-23 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2024-01-26 2024-02-23 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2024-01-26 2024-02-23 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-26 2024-02-23 N
Assist a resident in gaining access to vision and hearing services. Health 2024-01-26 2024-02-23 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2024-01-26 2024-02-23 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2024-01-26 2024-02-23 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-01-26 2024-02-23 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-01-26 2024-02-23 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 N
Ensure that residents are free from significant medication errors. Health 2024-01-26 2024-02-23 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 2024-01-26 2024-02-23 N
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. Health 2024-01-26 2024-02-23 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-01-26 2024-02-23 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-01-26 2024-02-23 N
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. Health 2024-01-26 2024-02-23 N
Provide and implement an infection prevention and control program. Health 2024-01-26 2024-02-23 N
Keep all essential equipment working safely. Health 2024-01-26 2024-02-23 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-01-26 2024-02-23 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-01-26 2024-02-23 Y
Provide or obtain dental services for each resident. Health 2024-01-26 2024-02-23 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-11 2024-02-02 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-01-11 2024-02-02 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-01-11 2024-02-02 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-01-11 2024-02-02 Y
Hire a qualified full-time social worker in a facility with more than 120 beds. Health 2024-01-11 2024-02-02 Y
Provide and implement an infection prevention and control program. Health 2024-01-11 2024-02-02 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-29 2023-12-12 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-29 2023-12-12 Y
Post nurse staffing information every day. Health 2023-11-29 2023-12-12 Y
Provide and implement an infection prevention and control program. Health 2023-11-29 2023-12-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-11-07 2023-12-02 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-11-07 2023-12-02 Y
Ensure that residents are free from significant medication errors. Health 2023-11-07 2023-12-02 Y
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 2023-11-07 2023-12-02 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-11-07 2023-12-02 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-10-29 2023-11-20 Y
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2023-10-29 2023-11-20 Y
Report COVID19 data to residents and families. Health 2023-10-29 2023-11-20 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-11-01 2023-11-16 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-11-01 2023-11-16 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-11-01 2023-11-16 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 2023-10-17 2023-11-02 Y
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. Health 2023-10-17 2023-11-02 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-05 2023-10-17 Y
Post nurse staffing information every day. Health 2023-09-13 2023-10-13 Y
Provide and implement an infection prevention and control program. Health 2023-09-13 2023-10-13 Y
Provide and implement an infection prevention and control program. Health 2023-07-25 2023-08-11 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-07-17 2023-08-10 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-07-17 2023-08-10 Y
Provide appropriate foot care. Health 2023-07-17 2023-08-10 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-07-14 2023-08-04 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-07-05 2023-07-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-05 2023-07-27 Y
Provide and implement an infection prevention and control program. Health 2023-07-05 2023-07-27 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 2023-06-16 2023-07-07 Y
Provide care by qualified persons according to each resident's written plan of care. Health 2023-06-16 2023-07-07 Y
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2023-06-16 2023-07-07 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-06-14 2023-06-23 Y
Ensure that residents are free from significant medication errors. Health 2023-04-17 2023-05-07 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2023-04-11 2023-05-03 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-04-12 2023-04-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-21 2023-03-21 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-02-21 2023-03-21 Y
List the names and contact information of those in the facility. Fire Safety 2023-01-30 2023-02-27 N
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2023-01-30 2023-02-27 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-01-30 2023-02-27 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-01-30 2023-02-27 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-01-30 2023-02-27 N
Construct fire resistant interior walls. Fire Safety 2023-01-30 2023-02-27 N
Install an approved automatic sprinkler system. Fire Safety 2023-01-30 2023-02-27 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-01-30 2023-02-27 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-01-30 2023-02-27 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-01-30 2023-02-27 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-01-30 2023-02-27 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-01-30 2023-02-27 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-01-30 2023-02-27 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-01-30 2023-02-27 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-01-30 2023-02-27 N
Have proper medical gas storage and administration areas. Fire Safety 2023-01-30 2023-02-27 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-01-20 2023-02-20 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-01-20 2023-02-20 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2023-01-20 2023-02-20 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-01-20 2023-02-20 N
Keep residents' personal and medical records private and confidential. Health 2023-01-20 2023-02-20 N
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 2023-01-20 2023-02-20 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-01-20 2023-02-20 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-01-20 2023-02-20 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-01-20 2023-02-20 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-20 2023-02-20 N
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Health 2023-01-20 2023-02-20 N
Provide enough food/fluids to maintain a resident's health. Health 2023-01-20 2023-02-20 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2023-01-20 2023-02-20 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-01-20 2023-02-20 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-01-20 2023-02-20 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-01-20 2023-02-20 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 2023-01-20 2023-02-20 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 2023-01-20 2023-02-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-01-20 2023-02-20 N
Provide and implement an infection prevention and control program. Health 2023-01-20 2023-02-20 N
Implement a program that monitors antibiotic use. Health 2023-01-20 2023-02-20 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 2023-01-20 2023-02-20 Y
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. Health 2023-01-20 2023-02-20 Y
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 2023-02-01 2023-02-13 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-27 2023-02-03 Y
Provide and implement an infection prevention and control program. Health 2023-01-27 2023-02-03 Y
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2022-11-21 2022-12-21 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-11-21 2022-12-21 Y
Report COVID19 data to residents and families. Health 2022-11-30 2022-12-09 Y
Provide appropriate foot care. Health 2022-10-18 2022-11-17 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-10-11 2022-11-11 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 2022-09-23 2022-10-24 Y
Keep all essential equipment working safely. Health 2022-09-23 2022-10-24 Y
Have enough outside ventilation via a window or mechanical ventilation, or both. Health 2022-09-23 2022-10-24 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-30 2022-09-09 Y
Provide and implement an infection prevention and control program. Health 2022-08-30 2022-09-09 Y
Provide or get specialized rehabilitative services as required for a resident. Health 2022-08-01 2022-09-02 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-07-28 2022-09-02 Y
Respond appropriately to all alleged violations. Health 2022-07-28 2022-09-02 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2022-07-28 2022-09-02 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-07-21 2022-08-25 Y
Provide routine and 24-hour emergency dental care for each resident. Health 2022-06-29 2022-07-15 Y
Provide and implement an infection prevention and control program. Health 2022-02-08 2022-02-18 N
Report COVID19 data to residents and families. Health 2022-02-08 2022-02-18 N
Post nurse staffing information every day. Health 2021-11-14 2021-11-26 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2021-11-15 2021-11-24 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-11-15 2021-11-24 Y
Provide and implement an infection prevention and control program. Health 2021-10-29 2021-11-04 Y
Address subsistence needs for staff and patients. Fire Safety 2019-07-24 2019-08-23 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2019-07-24 2019-08-23 N
Establish staff and initial training requirements. Fire Safety 2019-07-24 2019-08-23 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2019-07-24 2019-08-23 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-07-24 2019-08-23 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-07-24 2019-08-23 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-07-24 2019-08-23 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-07-24 2019-08-23 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-07-24 2019-08-23 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-07-24 2019-08-23 N
Have proper medical gas storage and administration areas. Fire Safety 2019-07-24 2019-08-23 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-07-12 2019-08-12 N
Reasonably accommodate the needs and preferences of each resident. Health 2019-07-12 2019-08-12 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2019-07-12 2019-08-12 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-07-12 2019-08-12 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2019-07-12 2019-08-12 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 2019-07-12 2019-08-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-07-12 2019-08-12 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-07-12 2019-08-12 N
Assist a resident in gaining access to vision and hearing services. Health 2019-07-12 2019-08-12 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-07-12 2019-08-12 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-07-12 2019-08-12 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 2019-07-12 2019-08-12 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2019-07-12 2019-08-12 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 2019-07-12 2019-08-12 N
Ensure that residents are free from significant medication errors. Health 2019-07-12 2019-08-12 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 2019-07-12 2019-08-12 N
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Health 2019-07-12 2019-08-12 N
Provide routine and 24-hour emergency dental care for each resident. Health 2019-07-12 2019-08-12 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2019-07-12 2019-08-12 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-07-12 2019-08-12 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-07-12 2019-08-12 N
Provide and implement an infection prevention and control program. Health 2019-07-12 2019-08-12 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2019-07-12 2019-08-12 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2019-07-12 2019-08-12 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2019-07-12 2019-08-12 N
Have enough backup water supply for essential areas of the nursing home. Health 2019-07-12 2019-08-12 N

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