A list of the most recent deficiencies for Bloomington Rehabilitation and Hcc. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-09 | 2024-02-02 | 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 | 2024-01-09 | 2024-02-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-09 | 2024-02-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-09 | 2024-02-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-09 | 2024-02-02 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-09 | 2024-02-02 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-09 | 2024-02-02 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-09 | 2024-02-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-09 | 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 | 2024-01-09 | 2024-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-09 | 2024-02-02 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-01-09 | 2024-02-02 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-01-09 | 2024-02-02 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-01-09 | 2024-02-02 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-01-09 | 2024-02-02 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide training in compliance and ethics. | Health | 2024-01-09 | 2024-02-02 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-17 | 2024-01-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-11 | 2024-01-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-11 | 2024-01-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-11 | 2024-01-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-11 | 2024-01-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-11 | 2024-01-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-24 | 2023-12-05 | 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 | 2023-11-05 | 2023-11-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-24 | 2023-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-24 | 2023-11-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-24 | 2023-11-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-29 | 2023-10-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-09 | 2023-10-05 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-08-22 | 2023-09-15 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-09 | 2023-09-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-09 | 2023-09-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-09 | 2023-09-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-09 | 2023-09-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-09 | 2023-09-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-09 | 2023-09-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-09 | 2023-09-05 | N |
| Provide activities to meet all resident's needs. | Health | 2023-08-09 | 2023-09-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-09 | 2023-09-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-09 | 2023-09-05 | N |
| Post nurse staffing information every day. | Health | 2023-08-09 | 2023-09-05 | 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 | 2023-08-09 | 2023-09-05 | N |
| 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 | 2023-08-09 | 2023-09-05 | 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 | 2023-08-09 | 2023-09-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-09 | 2023-09-05 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-09 | 2023-09-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-09 | 2023-09-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-08-09 | 2023-09-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-09 | 2023-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-09 | 2023-09-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-08-09 | 2023-09-05 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-09 | 2023-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | 2023-09-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Develop a communication plan. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-15 | 2023-09-05 | 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 | 2023-08-15 | 2023-09-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-15 | 2023-09-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-11 | 2023-07-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-11 | 2023-07-13 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-11 | 2023-07-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-11 | 2023-07-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-25 | 2023-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-25 | 2023-05-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-25 | 2023-05-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-25 | 2023-05-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-25 | 2023-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-25 | 2023-05-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-25 | 2023-05-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-25 | 2023-05-10 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-25 | 2023-05-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-25 | 2023-05-10 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-05 | 2023-04-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-23 | 2023-03-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-23 | 2023-03-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-23 | 2023-03-18 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-23 | 2023-03-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-10 | 2023-02-02 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-10 | 2023-02-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-10 | 2023-02-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-10 | 2023-02-02 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-10 | 2023-02-02 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-01-10 | 2023-02-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-10 | 2023-02-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-07 | 2022-12-31 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-07 | 2022-12-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-20 | 2022-12-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-04 | 2022-10-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-04 | 2022-10-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-09-28 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-07-27 | 2022-09-28 | 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 | 2022-08-10 | 2022-09-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-10 | 2022-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-10 | 2022-09-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-10 | 2022-09-02 | 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 | 2022-08-10 | 2022-09-02 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-10 | 2022-09-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-02 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-21 | 2022-08-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-21 | 2022-08-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-21 | 2022-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-21 | 2022-08-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-27 | 2022-08-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-27 | 2022-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-27 | 2022-08-17 | 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 | 2022-07-27 | 2022-08-17 | N |
| Post nurse staffing information every day. | Health | 2022-07-27 | 2022-08-17 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-07-27 | 2022-08-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-07-27 | 2022-08-17 | 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 | 2022-07-27 | 2022-08-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-27 | 2022-08-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-27 | 2022-08-17 | 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 | 2022-07-27 | 2022-08-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-27 | 2022-08-17 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-07-27 | 2022-08-17 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-27 | 2022-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-08-17 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-27 | 2022-08-17 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-07-27 | 2022-08-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-27 | 2022-08-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-19 | 2022-05-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-19 | 2022-05-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-19 | 2022-05-13 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-04-19 | 2022-05-13 | 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 | 2022-04-19 | 2022-05-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-19 | 2022-05-13 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-04-19 | 2022-05-13 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-19 | 2022-05-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-19 | 2022-05-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-19 | 2022-05-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-09 | 2022-03-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-09 | 2022-03-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-23 | 2022-03-16 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-23 | 2022-03-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-23 | 2022-03-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-23 | 2022-03-16 | 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 | 2022-02-23 | 2022-03-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-03-16 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-02-23 | 2022-03-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-23 | 2022-03-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-05 | 2022-01-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-05 | 2022-01-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-05 | 2022-01-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-05 | 2022-01-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-14 | 2021-12-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-14 | 2021-11-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-14 | 2021-11-01 | 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 | 2021-10-14 | 2021-11-01 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-10-14 | 2021-11-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-16 | 2021-09-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-16 | 2021-09-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-16 | 2021-09-05 | 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 | 2021-08-16 | 2021-09-05 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-06 | 2021-06-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-28 | 2021-05-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-28 | 2021-05-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-28 | 2021-05-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-04-28 | 2021-05-21 | 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 | 2021-04-28 | 2021-05-21 | N |
| 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 | 2021-04-28 | 2021-05-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-04-28 | 2021-05-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-28 | 2021-05-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-04-28 | 2021-05-21 | N |
