CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Santa Anita Convalescent Hospital
View the most recent health deficiencies and inspection results for Santa Anita Convalescent Hospital. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Santa Anita Convalescent Hospital. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-30 | 2026-05-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-04-07 | 2026-05-01 | Y |
| Honor the resident's right to choose his or her attending physician. | Health | 2026-03-05 | 2026-04-03 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2026-03-05 | 2026-04-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-01-05 | 2026-01-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-12-04 | 2025-12-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-11-05 | 2025-12-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-11-24 | 2025-11-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-28 | 2025-09-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-08-27 | 2025-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-27 | 2025-08-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-08-13 | 2025-08-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-08-15 | 2025-08-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-08-15 | 2025-08-24 | Y |
| Dispose of garbage and refuse properly. | Health | 2025-08-13 | 2025-08-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-07-31 | 2025-08-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-07-17 | 2025-08-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-07-17 | 2025-08-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-26 | 2025-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-26 | 2025-07-15 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2025-06-26 | 2025-07-15 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2025-06-26 | 2025-07-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-06-18 | 2025-07-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-06-17 | 2025-07-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-17 | 2025-07-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-06-17 | 2025-07-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-06-17 | 2025-07-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-06-26 | 2025-06-25 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2025-05-08 | 2025-06-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-05-08 | 2025-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-05-08 | 2025-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-05-08 | 2025-06-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-05-08 | 2025-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-05-08 | 2025-06-02 | 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 | 2025-05-08 | 2025-06-02 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-05-08 | 2025-06-01 | N |
| Dispose of garbage and refuse properly. | Health | 2025-05-08 | 2025-06-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-05-08 | 2025-06-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-05-08 | 2025-06-01 | 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 | 2025-05-08 | 2025-06-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2025-05-08 | 2025-06-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-05-08 | 2025-06-01 | 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 | 2025-05-08 | 2025-06-01 | 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 | 2025-05-08 | 2025-06-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-05-08 | 2025-06-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2025-05-08 | 2025-06-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-05-08 | 2025-06-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-05-08 | 2025-06-01 | 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 | 2025-05-08 | 2025-06-01 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2025-05-08 | 2025-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-05-08 | 2025-06-01 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2025-05-08 | 2025-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-05-08 | 2025-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-08 | 2025-06-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-05-08 | 2025-06-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-05-08 | 2025-06-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-05-08 | 2025-06-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-05-08 | 2025-06-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2025-05-08 | 2025-06-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-05-08 | 2025-06-01 | 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 | 2025-04-16 | 2025-05-06 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2025-04-16 | 2025-05-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-04-03 | 2025-04-24 | Y |
| Post nurse staffing information every day. | Health | 2025-04-03 | 2025-04-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-02-27 | 2025-03-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-02-25 | 2025-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-02-25 | 2025-02-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-02-21 | 2025-02-25 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2025-01-29 | 2025-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-01-29 | 2025-02-24 | 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 | 2025-01-29 | 2025-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-01-08 | 2025-01-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-08 | 2025-01-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-01-08 | 2025-01-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-10-18 | 2024-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-18 | 2024-11-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-26 | 2024-10-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-09-26 | 2024-10-18 | 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 | 2024-09-26 | 2024-10-18 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-09-25 | 2024-10-18 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-09-25 | 2024-10-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-25 | 2024-10-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-19 | 2024-10-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-19 | 2024-10-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-04 | 2024-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-04 | 2024-09-17 | 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 | 2024-08-26 | 2024-09-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-16 | 2024-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-16 | 2024-09-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-16 | 2024-09-06 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-08-16 | 2024-09-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-16 | 2024-09-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-16 | 2024-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-09 | 2024-08-26 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-08-09 | 2024-08-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-14 | 2024-08-26 | 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 | 2024-07-27 | 2024-08-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-27 | 2024-08-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-27 | 2024-08-23 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-25 | 2024-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-25 | 2024-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-25 | 2024-06-23 | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-25 | 2024-06-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-25 | 2024-06-23 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-05-25 | 2024-06-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-25 | 2024-06-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-25 | 2024-06-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-25 | 2024-06-23 | 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 | 2024-05-25 | 2024-06-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-25 | 2024-06-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-25 | 2024-06-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-10 | 2024-05-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-23 | 2024-05-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-23 | 2024-05-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-24 | 2024-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-19 | 2024-05-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-14 | 2024-05-09 | 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 | 2024-04-14 | 2024-05-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-03 | 2024-04-30 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-03-13 | 2024-03-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-06 | 2024-03-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-06 | 2024-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-13 | 2024-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-05 | 2024-03-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-27 | 2024-02-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-09 | 2024-02-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-08 | 2024-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-08 | 2024-01-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-27 | 2024-01-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-06 | 2024-01-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-15 | 2023-12-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | 2023-12-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-15 | 2023-12-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-13 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-06 | 2023-10-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-25 | 2023-10-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-01 | 2023-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-01 | 2023-08-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-01 | 2023-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-07-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-17 | N |
| Post nurse staffing information every day. | Health | 2023-05-17 | 2023-06-17 | 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 | 2023-05-17 | 2023-06-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-06-17 | 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 | 2023-05-17 | 2023-06-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-17 | 2023-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-17 | 2023-06-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-05-17 | 2023-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-17 | 2023-06-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-17 | 2023-06-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-17 | 2023-06-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-17 | 2023-06-17 | 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 | 2023-05-17 | 2023-06-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-17 | 2023-06-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-17 | 2023-06-16 | N |