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Deficiency Records for Bradley Estates Nursing and Rehab LLC
A list of the most recent deficiencies for Bradley Estates Nursing and Rehab LLC. 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 Bradley Estates Nursing and Rehab LLC. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-01 | 2024-07-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-01 | 2024-07-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-07-01 | 2024-07-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-01 | 2024-07-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-01 | 2024-07-17 | 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 | 2024-07-01 | 2024-07-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-07-01 | 2024-07-17 | 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 | 2024-07-01 | 2024-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-01 | 2024-07-17 | N |
| Keep all essential equipment working safely. | Health | 2024-07-01 | 2024-07-17 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-07-01 | 2024-07-17 | N |
| Provide training in compliance and ethics. | Health | 2024-07-01 | 2024-07-17 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-01 | 2024-07-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-01 | 2024-07-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-01 | 2024-07-17 | 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 | 2024-07-01 | 2024-07-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-01 | 2024-07-17 | 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 | 2024-07-01 | 2024-07-17 | 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 | 2024-07-01 | 2024-07-17 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-01 | 2024-07-17 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-27 | 2024-07-17 | 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 | 2024-06-27 | 2024-07-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-27 | 2024-07-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-07 | 2024-04-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-07 | 2024-04-05 | 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 | 2024-03-07 | 2024-04-05 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-07 | 2024-04-05 | 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 | 2024-03-07 | 2024-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-04-05 | 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 | 2024-03-07 | 2024-04-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-07 | 2024-04-05 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-07 | 2024-04-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-07 | 2024-04-05 | 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 | 2024-03-07 | 2024-04-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-03-07 | 2024-04-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-04-05 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-03-07 | 2024-04-05 | 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 | 2024-01-17 | 2024-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-17 | 2024-04-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-17 | 2024-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-17 | 2024-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2024-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-17 | 2024-02-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-17 | 2024-02-09 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-01-17 | 2024-02-09 | 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 | 2024-01-17 | 2024-02-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-01 | 2023-12-01 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-11-01 | 2023-12-01 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-01 | 2023-12-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-01 | 2023-12-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-01 | 2023-12-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-01 | 2023-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-12-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-01 | 2023-12-01 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-12-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-01 | 2023-12-01 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-25 | 2023-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-05-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-05-19 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-26 | 2023-05-19 | 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 | 2023-04-26 | 2023-05-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-26 | 2023-05-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-26 | 2023-05-19 | 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 | 2023-04-26 | 2023-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-26 | 2023-05-19 | 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 | 2023-04-26 | 2023-05-19 | 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 | 2023-04-26 | 2023-05-19 | 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 | 2023-04-26 | 2023-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-05-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-26 | 2023-05-19 | 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 | 2023-04-26 | 2023-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-05-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-05-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-26 | 2023-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-05-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-26 | 2023-05-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-26 | 2023-05-19 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-02 | 2023-03-07 | 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 | 2023-03-02 | 2023-03-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-02 | 2023-03-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-02 | 2023-03-07 | 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 | 2022-12-29 | 2023-03-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-29 | 2023-03-07 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-12-29 | 2023-03-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-29 | 2023-03-02 | 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 | 2022-12-29 | 2023-03-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-29 | 2023-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-29 | 2023-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-29 | 2023-03-02 | 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 | 2022-12-29 | 2023-03-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-29 | 2023-03-02 | 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 | 2022-12-29 | 2023-03-02 | 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 | 2022-12-29 | 2023-03-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-29 | 2023-03-02 | 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 | 2022-12-29 | 2023-03-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-29 | 2023-03-02 | 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 | 2022-07-16 | 2022-07-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-16 | 2022-07-19 | 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 | 2022-05-25 | 2022-07-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-25 | 2022-07-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-07-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-25 | 2022-07-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-05-25 | 2022-07-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-25 | 2022-07-16 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-10 | 2022-03-04 | 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 | 2022-02-10 | 2022-03-04 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-10 | 2022-03-04 | 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 | 2022-02-10 | 2022-03-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-03-04 | 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 | 2022-02-10 | 2022-03-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-10 | 2022-03-04 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-02-10 | 2022-03-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-04 | 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 | 2022-02-10 | 2022-03-04 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-10 | 2022-03-04 | Y |
| 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 | 2022-02-08 | 2022-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-01 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-27 | Not Fixed | N |
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