CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Accolade Healthcare of Savoy
A list of the most recent deficiencies for Accolade Healthcare of Savoy. 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 Accolade Healthcare of Savoy. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-24 | 2024-08-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-24 | 2024-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-20 | 2024-06-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-08 | 2024-05-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-08 | 2024-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-08 | 2024-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-02 | 2024-04-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-11 | 2024-03-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-11 | 2024-03-27 | 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 | 2024-02-10 | 2024-02-25 | 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 | 2024-02-10 | 2024-02-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-31 | 2024-02-21 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2024-01-31 | 2024-02-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-31 | 2024-02-21 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-15 | 2023-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-15 | 2023-12-08 | 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 | 2023-11-15 | 2023-12-08 | 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 | 2023-11-15 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-15 | 2023-12-08 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-15 | 2023-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-15 | 2023-12-08 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-11-20 | 2023-12-08 | 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 | 2023-11-20 | 2023-12-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-20 | 2023-12-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-22 | 2023-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-22 | 2023-10-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-08 | 2023-09-29 | 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 | 2023-09-08 | 2023-09-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-08 | 2023-09-29 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-08 | 2023-09-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-08 | 2023-09-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-26 | 2023-07-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-26 | 2023-07-26 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-06-26 | 2023-07-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-26 | 2023-07-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-26 | 2023-07-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-26 | 2023-07-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-26 | 2023-07-26 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-06-26 | 2023-07-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-26 | 2023-07-26 | Y |
| Provide appropriate foot care. | Health | 2023-06-26 | 2023-07-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-26 | 2023-07-26 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-26 | 2023-07-26 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-06-26 | 2023-07-26 | Y |
| Provide appropriate foot care. | Health | 2023-04-12 | 2023-04-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-12 | 2023-04-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-14 | 2023-04-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-14 | 2023-04-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-14 | 2023-04-10 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-05 | 2023-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-04-07 | Y |
| 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 | 2023-03-28 | 2023-03-31 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-09-14 | 2023-01-15 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-10-28 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-14 | 2022-10-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-14 | 2022-10-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-14 | 2022-10-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-10-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-25 | 2022-10-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-14 | 2022-10-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-14 | 2022-10-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-14 | 2022-10-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-14 | 2022-10-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-14 | 2022-10-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-13 | N |
| Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2022-09-14 | 2022-10-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-14 | 2022-10-13 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-14 | 2022-10-13 | 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 | 2022-09-14 | 2022-10-13 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-09-14 | 2022-10-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-14 | 2022-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-13 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-09-14 | 2022-10-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-09-14 | 2022-10-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-14 | 2022-10-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-14 | 2022-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-13 | N |
| 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. | Health | 2022-09-14 | 2022-10-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-14 | 2022-10-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-09-14 | 2022-10-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-14 | 2022-10-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-14 | 2022-10-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-14 | 2022-10-13 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-14 | 2022-10-13 | 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 | 2022-09-14 | 2022-10-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-14 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-13 | 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 | 2022-09-14 | 2022-10-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-14 | 2022-10-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-14 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-10-13 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-28 | 2022-10-13 | 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 | 2022-08-11 | 2022-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-10-13 | 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 | 2022-07-21 | 2022-10-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-21 | 2022-10-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-01 | 2022-10-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-22 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-10-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-22 | 2022-10-13 | 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 | 2022-06-02 | 2022-10-13 | 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 | 2022-06-02 | 2022-10-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-02 | 2022-10-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-02 | 2022-10-13 | 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 | 2022-05-25 | 2022-10-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-10-13 | 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 | 2022-05-25 | 2022-10-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-25 | 2022-10-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-25 | 2022-10-13 | 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 | 2022-05-12 | 2022-10-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-12 | 2022-10-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-03 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-03 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-22 | 2022-10-13 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-09-14 | 2022-10-04 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-09-14 | 2022-09-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-09-14 | 2022-09-28 | N |
| Establish methods for sharing information. | Fire Safety | 2022-09-14 | 2022-09-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-09-14 | 2022-09-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-09-14 | 2022-09-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-21 | 2022-08-26 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-01 | 2022-08-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-01 | 2022-08-26 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-22 | 2022-08-26 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-03 | 2022-08-26 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-04-22 | 2022-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-03-19 | 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 | 2022-02-11 | 2022-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-31 | 2022-02-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-31 | 2022-02-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-31 | 2022-02-17 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-01-31 | 2022-02-17 | 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 | 2022-01-31 | 2022-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-06 | 2022-01-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-06 | 2022-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-06 | 2022-01-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-15 | 2021-12-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-06 | 2021-12-24 | 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 | 2021-12-06 | 2021-12-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-07 | 2021-10-08 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-07-15 | 2021-08-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-15 | 2021-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-15 | 2021-08-17 | 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 | 2021-07-16 | 2021-08-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-16 | 2021-08-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-16 | 2021-08-07 | 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 | 2021-07-16 | 2021-08-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-16 | 2021-08-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
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