Deficiency Records for Santa Ana Healthcare and Wellness Centre, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Santa Ana Healthcare and Wellness Centre, LP. 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 all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-29 | 2024-02-15 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-29 | 2024-02-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-29 | 2024-02-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-10 | 2024-02-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-10 | 2024-02-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-10 | 2024-02-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-10 | 2024-02-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-13 | 2023-12-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2023-12-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-15 | 2023-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-04 | 2023-12-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-04 | 2023-12-12 | 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 | 2023-12-04 | 2023-12-12 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-15 | 2023-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-15 | 2023-12-08 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-15 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-11 | 2023-10-23 | 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 | 2023-09-21 | 2023-10-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-17 | Y |
| Provide appropriate foot care. | Health | 2023-09-21 | 2023-10-17 | 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 | 2023-09-21 | 2023-10-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-21 | 2023-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-21 | 2023-10-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-21 | 2023-10-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-07 | 2023-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-07 | 2023-08-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-07 | 2023-08-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-07 | 2023-08-25 | 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 | 2023-08-07 | 2023-08-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-07 | 2023-08-25 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-07 | 2023-08-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-15 | 2023-08-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-11 | 2023-08-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-28 | 2023-07-27 | 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 | 2023-06-14 | 2023-07-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-06 | 2023-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-06 | 2023-07-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-07-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-02 | 2023-07-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-01 | 2023-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-30 | 2023-06-29 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-18 | 2023-06-18 | 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 | 2023-05-18 | 2023-06-18 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-05-18 | 2023-06-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-17 | 2023-06-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-03 | 2023-06-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-06 | 2023-05-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-06 | 2023-05-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-24 | 2023-04-24 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-08 | 2023-04-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-08 | 2023-04-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-08 | 2023-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-07 | 2023-04-11 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2023-03-23 | 2023-03-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-06 | 2023-02-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-06 | 2023-02-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-01-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-07 | 2023-01-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-19 | 2022-11-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-03 | 2022-09-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-02 | 2022-09-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-02 | 2022-09-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-10 | 2022-06-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-04-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-22 | 2022-04-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-22 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-22 | 2022-04-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-25 | 2022-02-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-25 | 2022-02-19 | 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 | 2021-11-04 | 2021-12-03 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-11-04 | 2021-12-03 | 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 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-12-03 | 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 | 2021-12-03 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-30 | 2021-10-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-09 | 2021-10-09 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-08-31 | 2021-09-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-31 | 2021-09-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-31 | 2021-09-30 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-08-31 | 2021-09-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-31 | 2021-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-31 | 2021-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-31 | 2021-09-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-31 | 2021-09-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| 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 | 2021-08-31 | 2021-09-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-31 | 2021-09-30 | 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 | 2021-08-31 | 2021-09-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-31 | 2021-09-30 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-08-31 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-31 | 2021-09-30 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-08-31 | 2021-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-31 | 2021-09-30 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-08-31 | 2021-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-31 | 2021-09-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-31 | 2021-09-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-31 | 2021-09-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-31 | 2021-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2021-08-06 | 2021-09-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-10 | 2021-06-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-29 | 2021-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-29 | 2021-05-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-29 | 2021-05-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-14 | 2021-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-11 | 2019-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-11 | 2019-05-13 | 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 | 2019-03-11 | 2019-05-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-25 | 2019-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-11 | 2019-04-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-11 | 2019-04-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-03-11 | 2019-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-11 | 2019-04-26 | 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 | 2019-03-11 | 2019-04-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-11 | 2019-04-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-03-11 | 2019-04-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-03-11 | 2019-04-26 | N |
| Dispose of garbage and refuse properly. | Health | 2019-03-11 | 2019-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-11 | 2019-04-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-03-11 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-11 | 2019-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-11 | 2019-04-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-15 | 2018-06-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-28 | 2018-04-28 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-03-28 | 2018-04-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-28 | 2018-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-28 | 2018-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-28 | 2018-04-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-28 | 2018-04-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | 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 | 2018-03-28 | 2018-04-28 | N |
| Dispose of garbage and refuse properly. | Health | 2018-03-28 | 2018-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-28 | 2018-04-28 | N |
