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Deficiency Records for Hagerstown Healthcare Center
A list of the most recent deficiencies for Hagerstown Healthcare Center. 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 Hagerstown Healthcare Center. 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 and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-13 | 2024-03-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-13 | 2024-03-05 | 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 | 2023-12-22 | 2024-02-02 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-22 | 2024-02-02 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-22 | 2024-02-02 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-22 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-22 | 2024-02-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-12-22 | 2024-02-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| 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 | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-22 | 2024-02-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-22 | 2024-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-22 | 2024-02-02 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-12-22 | 2024-02-02 | N |
| 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 | 2023-12-22 | 2024-02-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-22 | 2024-02-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-22 | 2024-02-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-22 | 2024-02-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-22 | 2024-02-02 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-13 | 2024-01-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-13 | 2024-01-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-13 | 2024-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-13 | 2024-01-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-13 | 2024-01-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-13 | 2024-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-21 | 2023-09-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-13 | 2023-04-24 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-13 | 2023-04-24 | Y |
| 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. | Health | 2023-01-13 | 2023-04-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-13 | 2023-04-24 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-13 | 2023-04-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-13 | 2023-04-24 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-01-13 | 2023-04-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-13 | 2023-04-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-04-24 | 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 | 2023-01-13 | 2023-02-27 | 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 | 2023-01-13 | 2023-02-27 | 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 | 2023-01-13 | 2023-02-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-13 | 2023-02-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-13 | 2023-02-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-13 | 2023-02-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-13 | 2023-02-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-13 | 2023-02-27 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-01-13 | 2023-02-27 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-13 | 2023-02-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-02-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-02-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-13 | 2023-02-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-13 | 2023-02-27 | 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 | 2023-01-13 | 2023-02-27 | 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 | 2023-01-13 | 2023-02-27 | 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 | 2023-01-13 | 2023-02-27 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-01-13 | 2023-02-27 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-13 | 2023-02-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-13 | 2023-02-27 | 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 | 2023-01-13 | 2023-02-27 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-13 | 2023-02-27 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-01-13 | 2023-02-27 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-13 | 2023-02-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-14 | 2023-01-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-14 | 2023-01-18 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-01-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-03 | 2021-12-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-03 | 2021-12-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-03 | 2021-12-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-03 | 2021-12-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-03 | 2021-12-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-12-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-03 | 2021-12-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-03 | 2021-12-17 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-03 | 2021-12-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-03 | 2021-12-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-03 | 2021-12-17 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-11-03 | 2021-12-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-12-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-03 | 2021-12-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-03 | 2021-12-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-03 | 2021-12-17 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Post nurse staffing information every day. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-03 | 2021-12-17 | 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 | 2021-11-03 | 2021-12-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-03 | 2021-12-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-03 | 2021-12-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-03 | 2021-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-03 | 2021-12-17 | Y |
| 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 | 2021-11-03 | 2021-12-17 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2021-11-03 | 2021-12-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-08 | 2019-08-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-08 | 2019-08-27 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-04-08 | 2019-08-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-08 | 2019-08-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-08 | 2019-08-27 | 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 | 2019-04-08 | 2019-08-27 | 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 | 2019-04-08 | 2019-08-27 | 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 | 2019-04-08 | 2019-08-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-08 | 2019-08-27 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-04-08 | 2019-06-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-08 | 2019-06-24 | 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 | 2019-04-08 | 2019-06-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-08 | 2019-06-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-08 | 2019-06-24 | 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 | 2019-04-08 | 2019-06-24 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-08 | 2019-06-24 | N |
| 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. | Health | 2019-04-08 | 2019-06-24 | 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 | 2019-04-08 | 2019-06-24 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2019-04-08 | 2019-06-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-08 | 2019-06-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-08 | 2019-06-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-08 | 2019-06-24 | 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 | 2019-04-08 | 2019-06-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-08 | 2019-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-08 | 2019-06-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-04-08 | 2019-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-08 | 2019-06-24 | 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 | 2019-04-08 | 2019-06-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-08 | 2019-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-08 | 2019-06-24 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-04-08 | 2019-06-24 | N |
| Post nurse staffing information every day. | Health | 2019-04-08 | 2019-06-24 | N |
| 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 | 2019-04-08 | 2019-06-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-08 | 2019-06-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-08 | 2019-06-24 | 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 | 2019-04-08 | 2019-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-08 | 2019-06-24 | N |
| 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 | 2019-04-08 | 2019-06-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-08 | 2019-06-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-04-08 | 2019-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-06-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-04-08 | 2019-06-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-08 | 2019-06-24 | N |
| Meet other general requirements. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-10 | 2019-05-31 | 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 | 2019-04-10 | 2019-05-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-10 | 2019-05-31 | 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 | 2017-10-30 | 2017-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-10-30 | 2017-12-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-30 | 2017-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-26 | 2017-12-04 | N |
| Provide housekeeping and maintenance services. | Health | 2017-10-26 | 2017-12-04 | N |
| Maintain comfortable and safe temperature levels. | Health | 2017-10-26 | 2017-12-04 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-26 | 2017-12-04 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-26 | 2017-12-04 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-10-26 | 2017-12-04 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-26 | 2017-12-04 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-10-26 | 2017-12-04 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-26 | 2017-12-04 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-10-26 | 2017-12-04 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-26 | 2017-12-04 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-26 | 2017-12-04 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-10-26 | 2017-12-04 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-26 | 2017-12-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-10-26 | 2017-12-04 | N |
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