A list of the most recent deficiencies for The Loft Rehab of Rock Springs. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-30 | 2024-02-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-30 | 2024-02-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-30 | 2024-02-21 | Y |
| Keep all essential equipment working safely. | Health | 2024-01-30 | 2024-02-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2024-02-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-03 | 2024-01-18 | 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 | 2024-01-03 | 2024-01-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-03 | 2024-01-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-20 | 2024-01-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-20 | 2024-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-20 | 2024-01-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-16 | 2023-10-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-08-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-10 | 2023-08-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-28 | 2023-07-05 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-28 | 2023-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-16 | 2023-06-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-10 | 2023-06-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-10 | 2023-06-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-10 | 2023-06-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-06-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-10 | 2023-06-09 | 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 | 2023-05-04 | 2023-06-08 | 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 | 2023-05-04 | 2023-06-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-10 | 2023-06-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-06-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-04 | 2023-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-04 | 2023-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-06-01 | 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 | 2023-05-04 | 2023-06-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-04 | 2023-06-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-04 | 2023-06-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-04 | 2023-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-06-01 | 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 | 2023-05-04 | 2023-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-04 | 2023-06-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-04 | 2023-06-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-04 | 2023-06-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-04 | 2023-06-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-04 | 2023-06-01 | 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 | 2023-05-04 | 2023-06-01 | 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 | 2023-05-04 | 2023-06-01 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-04 | 2023-06-01 | 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 | 2023-05-04 | 2023-06-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-04 | 2023-06-01 | 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 | 2023-05-04 | 2023-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-06-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-04 | 2023-06-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-10 | 2023-05-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-10 | 2023-05-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Develop a communication plan. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-10 | 2023-05-23 | 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 | 2023-05-10 | 2023-05-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-10 | 2023-05-23 | N |
| Provide appropriate foot care. | Health | 2023-03-01 | 2023-03-14 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-03-01 | 2023-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-19 | 2023-02-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-19 | 2023-02-10 | 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 | 2022-09-07 | 2022-09-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-03 | 2022-09-16 | 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 | 2022-08-03 | 2022-09-16 | 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 | 2022-08-03 | 2022-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-03 | 2022-09-16 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-04 | 2022-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-04 | 2022-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-04 | 2022-09-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-08-04 | 2022-09-02 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-03 | 2022-08-31 | 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 | 2022-08-03 | 2022-08-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-03 | 2022-08-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-03 | 2022-08-31 | 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 | 2022-08-03 | 2022-08-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-03 | 2022-08-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-03 | 2022-08-31 | 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 | 2022-08-03 | 2022-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-03 | 2022-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-08-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-03 | 2022-08-31 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-08-03 | 2022-08-31 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-03 | 2022-08-31 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-03 | 2022-08-31 | 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 | 2022-08-03 | 2022-08-31 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-08-03 | 2022-08-31 | 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 | 2022-08-03 | 2022-08-31 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-03 | 2022-08-31 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-04 | 2022-08-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-04 | 2022-08-26 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-04 | 2022-08-25 | 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 | 2022-08-04 | 2022-08-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2022-08-04 | 2022-08-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-04 | 2022-08-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-04 | 2022-08-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-07 | 2022-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-07-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-19 | 2022-07-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-19 | 2022-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-19 | 2022-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-19 | 2022-07-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-15 | 2022-07-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-15 | 2022-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-15 | 2022-07-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-15 | 2022-07-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-15 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-06 | 2022-06-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-26 | 2022-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-06-17 | 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 | 2022-05-26 | 2022-06-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-23 | 2022-06-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-23 | 2022-06-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-23 | 2022-06-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-23 | 2022-06-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-30 | 2022-05-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-08 | 2022-03-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-08 | 2022-03-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-08 | 2022-03-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-08 | 2022-03-24 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-08 | 2022-03-24 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-01-06 | 2022-01-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-07 | 2021-12-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-12-09 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-07 | 2021-12-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-21 | 2021-12-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-21 | 2021-12-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-21 | 2021-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-21 | 2021-12-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-21 | 2021-12-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-10-21 | 2021-12-02 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-10-21 | 2021-12-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-21 | 2021-12-02 | 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 | 2021-10-21 | 2021-12-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-21 | 2021-12-02 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-21 | 2021-12-02 | 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 | 2021-10-21 | 2021-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-12-02 | 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 | 2021-10-21 | 2021-12-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-21 | 2021-12-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-21 | 2021-12-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-21 | 2021-12-02 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Develop a communication plan. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Establish methods for sharing information. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-09 | 2021-11-24 | 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 | 2021-11-09 | 2021-11-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-03 | 2021-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-03 | 2021-11-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-11-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-03 | 2021-11-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-21 | 2021-10-15 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-09-21 | 2021-10-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-21 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-21 | 2021-10-15 | Y |
| 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 | 2021-09-21 | 2021-10-15 | 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 | 2021-09-21 | 2021-10-15 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-09-21 | 2021-10-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-21 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-28 | 2021-10-01 | Y |
| Report COVID19 data to residents and families. | Health | 2021-09-28 | 2021-10-01 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-28 | 2021-10-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-10-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-09-27 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-21 | 2021-09-25 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-23 | 2021-09-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-23 | 2021-09-10 | 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 | 2021-08-04 | 2021-09-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-11 | 2021-09-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-04 | 2021-08-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-24 | 2021-07-15 | 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 | 2021-05-25 | 2021-05-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-19 | 2021-05-23 | 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 | 2021-05-19 | 2021-05-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-19 | 2021-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-23 | 2021-05-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-11 | 2021-04-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-11 | 2021-04-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-11 | 2021-04-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-11 | 2021-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-11 | 2021-04-01 | Y |
| Provide appropriate foot care. | Health | 2021-03-11 | 2021-04-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-11 | 2021-04-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-11 | 2021-04-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-11 | 2021-04-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-11 | 2021-04-01 | Y |
