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Deficiency Records for Mirage Post Acute
View the most recent health deficiencies and inspection results for Mirage Post Acute. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Mirage Post Acute. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2026-04-24 | 2026-05-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-04-24 | 2026-05-15 | 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 | 2026-04-24 | 2026-05-15 | 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 | 2026-04-24 | 2026-05-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2026-04-24 | 2026-05-15 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2026-04-24 | 2026-05-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-24 | 2026-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-04-24 | 2026-05-15 | 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 | 2026-04-24 | 2026-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-04-24 | 2026-05-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2026-04-24 | 2026-05-15 | 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 | 2026-04-24 | 2026-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-24 | 2026-05-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2026-04-24 | 2026-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-04-24 | 2026-05-15 | 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 | 2026-04-24 | 2026-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2026-04-24 | 2026-05-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2026-04-24 | 2026-05-15 | 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 | 2026-04-24 | 2026-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2026-04-24 | 2026-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2026-04-24 | 2026-05-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2026-04-24 | 2026-05-15 | N |
| Keep all essential equipment working safely. | Health | 2026-04-24 | 2026-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-04-28 | 2026-05-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-04-28 | 2026-05-11 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2026-04-24 | 2026-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-04-24 | 2026-04-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2026-04-24 | 2026-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2026-04-24 | 2026-04-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2026-04-24 | 2026-04-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2026-04-24 | 2026-04-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-03-06 | 2026-03-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-01-30 | 2026-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-01-30 | 2026-03-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-01-30 | 2026-03-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2026-01-30 | 2026-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-01-30 | 2026-03-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-01-30 | 2026-03-02 | Y |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2026-01-30 | 2026-03-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-01-20 | 2026-02-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2026-01-20 | 2026-02-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2026-02-02 | 2026-02-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-12-17 | 2025-12-24 | 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 | 2025-11-25 | 2025-11-26 | 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 | 2025-11-24 | 2025-11-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-11-24 | 2025-11-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-11-24 | 2025-11-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-11-24 | 2025-11-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-09-05 | 2025-09-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-09-05 | 2025-09-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-08-21 | 2025-09-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2025-09-05 | 2025-09-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-09-05 | 2025-09-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-09-05 | 2025-09-26 | 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 | 2025-08-21 | 2025-09-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-21 | 2025-09-19 | 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 | 2025-08-21 | 2025-09-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-21 | 2025-09-19 | 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 | 2025-08-21 | 2025-09-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-08-21 | 2025-09-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2025-08-07 | 2025-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-08-07 | 2025-09-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-08-07 | 2025-09-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-08-07 | 2025-09-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-07-22 | 2025-08-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-07-15 | 2025-08-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-07-09 | 2025-07-31 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-07-09 | 2025-07-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-07-09 | 2025-07-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-07-09 | 2025-07-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-06-05 | 2025-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-06-05 | 2025-06-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-05-16 | 2025-06-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-05-16 | 2025-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-05-16 | 2025-06-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-05-16 | 2025-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-04-03 | 2025-04-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-04-03 | 2025-04-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-04-03 | 2025-04-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-04-03 | 2025-04-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-03 | 2025-04-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-04-03 | 2025-04-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-03-28 | 2025-04-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-28 | 2025-04-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-03-28 | 2025-04-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-03-28 | 2025-04-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-03-12 | 2025-04-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-03-12 | 2025-04-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-03-10 | 2025-03-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-03-10 | 2025-03-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-11 | 2025-03-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-11 | 2025-03-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-11 | 2025-03-13 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2025-02-25 | 2025-02-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-02-07 | 2025-02-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-02-25 | 2025-02-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2025-02-04 | 2025-02-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-02-04 | 2025-02-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-01-17 | 2025-02-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-01-17 | 2025-02-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-01-17 | 2025-02-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-01-17 | 2025-02-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-01-17 | 2025-02-05 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2025-01-17 | 2025-02-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-17 | 2025-02-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-01-17 | 2025-02-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-01-17 | 2025-02-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2025-01-17 | 2025-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-01-17 | 2025-02-05 | 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 | 2025-01-17 | 2025-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-01-17 | 2025-02-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-01-17 | 2025-02-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-01-17 | 2025-02-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-01-17 | 2025-02-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-01-17 | 2025-02-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-01-17 | 2025-02-05 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2025-01-17 | 2025-02-05 | N |
| Dispose of garbage and refuse properly. | Health | 2025-01-17 | 2025-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-17 | 2025-02-05 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-01-17 | 2025-02-05 | 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 | 2025-01-28 | 2025-01-30 | 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 | 2025-01-28 | 2025-01-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-01-28 | 2025-01-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-01-22 | 2025-01-25 | Y |
| Post nurse staffing information every day. | Health | 2025-01-22 | 2025-01-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-01-22 | 2025-01-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-01-06 | 2025-01-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-01-06 | 2025-01-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-01-06 | 2025-01-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-01-06 | 2025-01-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-01-07 | 2025-01-20 | 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 | 2024-12-19 | 2025-01-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-12-19 | 2025-01-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-12-19 | 2025-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-12-19 | 2025-01-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-12-12 | 2024-12-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-12-06 | 2024-12-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-11-25 | 2024-12-16 | 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 | 2024-11-25 | 2024-12-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-11-25 | 2024-12-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-11-15 | 2024-12-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-11-15 | 2024-12-12 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-11-15 | 2024-12-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-11-13 | 2024-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-11-13 | 2024-12-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-11-13 | 2024-12-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-13 | 2024-12-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-11-13 | 2024-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-11-14 | 2024-11-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-03 | 2024-10-22 | 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 | 2024-10-03 | 2024-10-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-08 | 2024-10-21 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-10-08 | 2024-10-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-08 | 2024-10-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-28 | 2024-10-18 | 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 | 2024-09-28 | 2024-10-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-28 | 2024-10-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-28 | 2024-10-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-28 | 2024-10-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-28 | 2024-10-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-28 | 2024-10-18 | 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 | 2024-09-28 | 2024-10-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-28 | 2024-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-28 | 2024-10-18 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-09-28 | 2024-10-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-28 | 2024-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-03 | 2024-09-23 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-08-08 | 2024-08-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-08 | 2024-08-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-11 | 2024-07-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-06 | 2024-05-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-06 | 2024-05-24 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-05-06 | 2024-05-24 | 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 | 2024-05-01 | 2024-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-01 | 2024-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-16 | 2024-04-25 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-03-18 | 2024-04-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-18 | 2024-04-04 | 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 | 2024-03-18 | 2024-04-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-18 | 2024-04-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-18 | 2024-04-04 | 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 | 2024-03-18 | 2024-04-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-18 | 2024-04-04 | Y |
| Keep all essential equipment working safely. | Health | 2024-03-18 | 2024-04-04 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-03-18 | 2024-04-04 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-26 | 2024-02-29 | 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 | 2024-01-26 | 2024-02-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-26 | 2024-02-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-26 | 2024-02-29 | 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 | 2024-01-26 | 2024-02-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-26 | 2024-02-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-01-26 | 2024-02-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-02-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-26 | 2024-02-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-26 | 2024-02-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-26 | 2024-02-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-26 | 2024-02-23 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-26 | 2024-02-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-26 | 2024-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-26 | 2024-02-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-26 | 2024-02-23 | Y |
| Keep all essential equipment working safely. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-26 | 2024-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-26 | 2024-02-23 | 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 | 2024-01-26 | 2024-02-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-01-26 | 2024-02-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-26 | 2024-02-23 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-11 | 2024-02-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-11 | 2024-02-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-11 | 2024-02-02 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-01-11 | 2024-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-29 | 2023-12-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-29 | 2023-12-12 | Y |
| Post nurse staffing information every day. | Health | 2023-11-29 | 2023-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-29 | 2023-12-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-07 | 2023-12-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-07 | 2023-12-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-07 | 2023-12-02 | 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 | 2023-11-07 | 2023-12-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-07 | 2023-12-02 | Y |
| Report COVID19 data to residents and families. | Health | 2023-10-29 | 2023-11-20 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-10-29 | 2023-11-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-29 | 2023-11-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-01 | 2023-11-16 | 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 | 2023-11-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-01 | 2023-11-16 | 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 | 2023-10-17 | 2023-11-02 | 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 | 2023-10-17 | 2023-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-17 | Y |
| Post nurse staffing information every day. | Health | 2023-09-13 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-25 | 2023-08-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-17 | 2023-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-17 | 2023-08-10 | Y |
| Provide appropriate foot care. | Health | 2023-07-17 | 2023-08-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-14 | 2023-08-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-05 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-05 | 2023-07-27 | 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 | 2023-06-16 | 2023-07-07 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-06-16 | 2023-07-07 | 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 | 2023-06-16 | 2023-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-14 | 2023-06-23 | Y |