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Deficiency Records for Aspen Point Health and Rehabilitation

A list of the most recent deficiencies for Aspen Point Health and Rehabilitation. 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 Aspen Point Health and Rehabilitation. 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?
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-06-05 2024-07-30 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-04-17 2024-07-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-04-17 2024-07-30 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-04-17 2024-07-30 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-02-23 2024-07-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-02-23 2024-07-30 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-02-23 2024-07-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-05-02 2024-05-14 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 2024-04-17 2024-05-14 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 2024-04-17 2024-05-14 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 2024-04-17 2024-05-14 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 2024-02-23 2024-05-14 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 2024-02-23 2024-05-14 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 2024-02-23 2024-05-14 Y
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 2024-02-23 2024-05-14 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 2024-02-23 2024-03-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-23 2024-03-25 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-02-23 2024-03-25 N
Ensure that residents are free from significant medication errors. Health 2024-02-23 2024-03-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-02-23 2024-03-25 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 2024-02-23 2024-03-25 N
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Health 2024-02-23 2024-03-25 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2024-02-23 2024-03-25 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-02-23 2024-03-25 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-02-23 2024-03-25 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2024-02-23 2024-03-25 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-02-23 2024-03-25 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2024-02-23 2024-03-25 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-02-23 2024-03-25 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2024-01-18 2024-02-01 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-08-15 2024-02-01 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-12-14 2024-01-10 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 2023-12-14 2024-01-10 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-14 2024-01-10 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-12-14 2024-01-10 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-11-09 2023-12-08 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-09 2023-12-08 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 2023-11-09 2023-12-08 Y
Provide and implement an infection prevention and control program. Health 2023-11-09 2023-12-08 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-12 2023-12-08 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-08-15 2023-12-08 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-15 2023-12-08 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 2023-08-15 2023-12-08 Y
Provide and implement an infection prevention and control program. Health 2023-08-15 2023-12-08 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2023-12-04 2023-11-10 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-10-12 2023-10-30 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-10-12 2023-10-30 Y
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 2023-10-12 2023-10-30 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-10-12 2023-10-30 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 2023-10-12 2023-10-30 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 2023-10-12 2023-10-30 Y
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 2023-10-12 2023-10-30 Y
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2023-10-12 2023-10-30 Y
Implement a program that monitors antibiotic use. Health 2023-10-12 2023-10-30 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2023-10-12 2023-10-30 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 2023-10-12 2023-10-16 Y
Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. Health 2023-08-15 2023-09-19 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-15 2023-09-19 Y
Respond appropriately to all alleged violations. Health 2023-08-15 2023-09-19 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-08-15 2023-09-19 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-08-15 2023-09-19 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-08-15 2023-09-19 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 2023-05-12 2023-06-08 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-05-12 2023-06-08 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-05-12 2023-06-08 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-05-12 2023-06-08 Y
Ensure that residents are free from significant medication errors. Health 2023-05-12 2023-06-08 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2023-05-12 2023-06-08 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 2023-04-17 2023-06-08 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-04-17 2023-06-08 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-04-17 2023-06-08 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-02-07 2023-06-08 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 2023-02-07 2023-06-08 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 2023-02-07 2023-06-08 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-02-07 2023-06-08 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2023-02-07 2023-06-08 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 2023-01-05 2023-06-08 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-01-05 2023-06-08 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-12-19 2023-06-08 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 2022-12-19 2023-06-08 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 2022-12-19 2023-06-08 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-12-19 2023-06-08 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-12-19 2023-06-08 Y
Respond appropriately to all alleged violations. Health 2023-03-16 2023-04-11 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-03-16 2023-04-11 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-02-07 2023-04-04 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-02-07 2023-04-04 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-02-07 2023-04-04 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 2023-02-07 2023-04-04 Y
Post nurse staffing information every day. Health 2023-02-07 2023-04-04 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-12-19 2023-04-04 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-12-19 2023-03-27 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-12-19 2023-03-27 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-12-19 2023-03-27 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 2022-12-19 2023-03-27 Y
Post nurse staffing information every day. Health 2022-12-19 2023-03-27 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-12-19 2023-03-27 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2023-01-05 2023-01-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-12-19 2023-01-20 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-12-19 2023-01-20 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-09-09 2022-09-27 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-09-09 2022-09-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-31 2022-09-27 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-10-04 2022-03-14 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 2021-10-04 2022-03-14 Y
Respond appropriately to all alleged violations. Health 2021-10-04 2022-03-14 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-10-04 2022-03-14 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-10-04 2022-03-14 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2021-10-04 2022-03-14 Y
Respond appropriately to all alleged violations. Health 2022-02-02 2022-03-14 Y
Conduct risk assessment and an All-Hazards approach. Fire Safety 2021-10-04 2022-03-14 N
Address patient/client population and determine types of services needed. Fire Safety 2021-10-04 2022-03-14 N
Establish policies and procedures for volunteers. Fire Safety 2021-10-04 2022-03-14 N
List the names and contact information of those in the facility. Fire Safety 2021-10-04 2022-03-14 N
Establish methods for sharing information. Fire Safety 2021-10-04 2022-03-14 N
Implement emergency and standby power systems. Fire Safety 2021-10-04 2022-03-14 N
Use approved construction type or materials. Fire Safety 2021-10-04 2022-03-14 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2021-10-04 2022-03-14 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-10-04 2022-03-14 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-10-04 2022-03-14 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-10-04 2022-03-14 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-10-04 2022-02-02 Y
Reasonably accommodate the needs and preferences of each resident. Health 2021-10-04 2022-01-18 N
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
Provide appropriate foot care. Health 2021-10-04 2022-01-18 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-10-04 2022-01-18 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
Post nurse staffing information every day. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2021-10-04 2022-01-18 N
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
Dispose of garbage and refuse properly. Health 2021-10-04 2022-01-18 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2021-10-04 2022-01-18 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2021-10-04 2022-01-18 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-10-04 2022-01-18 N
Implement a program that monitors antibiotic use. Health 2021-10-04 2022-01-18 N
Keep all essential equipment working safely. Health 2021-10-04 2022-01-18 N
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-10-04 2022-01-18 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2021-10-04 2022-01-18 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-10-04 2022-01-18 Y
Keep residents' personal and medical records private and confidential. Health 2021-10-04 2022-01-18 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-10-04 2022-01-18 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2021-10-04 2022-01-18 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-10-04 2022-01-18 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-10-04 2022-01-18 Y
Provide activities to meet all resident's needs. Health 2021-10-04 2022-01-18 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-10-04 2022-01-18 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-10-04 2022-01-18 Y
Provide and implement an infection prevention and control program. Health 2021-10-04 2022-01-18 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-10-04 2022-01-18 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2021-10-04 2022-01-18 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2021-10-04 2022-01-18 N
Address subsistence needs for staff and patients. Fire Safety 2021-10-04 2022-01-18 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2021-10-04 2022-01-18 N
Establish policies and procedures including evacuation. Fire Safety 2021-10-04 2022-01-18 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-10-04 2022-01-18 N
Establish roles under a Waiver declared by secretary. Fire Safety 2021-10-04 2022-01-18 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2021-10-04 2022-01-18 N
Establish emergency prep training and testing. Fire Safety 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 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 2021-10-04 2022-01-18 N
Provide properly protected cooking facilities. Fire Safety 2021-10-04 2022-01-18 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2021-10-04 2022-01-18 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-10-04 2022-01-18 N
Provide a written emergency evacuation plan. Fire Safety 2021-10-04 2022-01-18 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-10-04 2022-01-18 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-10-04 2022-01-18 N
Meet other general requirements. Fire Safety 2021-10-04 2022-01-18 N
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Health 2020-10-13 2020-11-13 N
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2020-10-13 2020-11-13 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 2020-10-13 2020-11-13 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2020-10-13 2020-11-13 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2020-10-13 2020-11-13 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-10-13 2020-11-13 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-10-13 2020-11-13 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2020-10-13 2020-11-13 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-10-13 2020-11-13 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 2020-10-13 2020-11-13 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 2020-10-13 2020-11-13 N
Post nurse staffing information every day. Health 2020-10-13 2020-11-13 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2020-10-13 2020-11-13 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 2020-10-13 2020-11-13 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 2020-10-13 2020-11-13 N
Ensure medication error rates are not 5 percent or greater. Health 2020-10-13 2020-11-13 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2020-10-13 2020-11-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-10-13 2020-11-13 N
Provide and implement an infection prevention and control program. Health 2020-10-13 2020-11-13 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2020-10-13 2020-11-13 N
Use approved construction type or materials. Fire Safety 2020-10-13 2020-11-13 N
Have properly located and lighted "Exit" signs. Fire Safety 2020-10-13 2020-11-13 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 2020-10-13 2020-11-13 N
Provide properly protected cooking facilities. Fire Safety 2020-10-13 2020-11-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-10-13 2020-11-13 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2020-10-13 2020-11-13 N
Install corridor and hallway doors that block smoke. Fire Safety 2020-10-13 2020-11-13 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2020-10-13 2020-11-13 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-10-13 2020-11-13 N
Have proper medical gas storage and administration areas. Fire Safety 2020-10-13 2020-11-13 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-02-23 Not Fixed N

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