Deficiency Records for Aspen Point Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Aspen Point Health and Rehabilitation. 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 | 2024-01-18 | 2024-02-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-15 | 2024-02-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-15 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-15 | 2023-12-08 | 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 | 2023-08-15 | 2023-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-15 | 2023-12-08 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2023-08-15 | 2023-09-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-15 | 2023-09-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-15 | 2023-09-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-15 | 2023-09-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-15 | 2023-09-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-15 | 2023-09-19 | 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 | 2023-05-12 | 2023-06-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-12 | 2023-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-12 | 2023-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-12 | 2023-06-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-12 | 2023-06-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-12 | 2023-06-08 | 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 | 2023-04-17 | 2023-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-17 | 2023-06-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-17 | 2023-06-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-07 | 2023-06-08 | 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 | 2023-02-07 | 2023-06-08 | 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 | 2023-02-07 | 2023-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-07 | 2023-06-08 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-07 | 2023-06-08 | 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 | 2023-01-05 | 2023-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-05 | 2023-06-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-19 | 2023-06-08 | 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 | 2022-12-19 | 2023-06-08 | 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 | 2022-12-19 | 2023-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-19 | 2023-06-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-19 | 2023-06-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-16 | 2023-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-07 | 2023-04-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-07 | 2023-04-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-07 | 2023-04-04 | 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 | 2023-02-07 | 2023-04-04 | Y |
| Post nurse staffing information every day. | Health | 2023-02-07 | 2023-04-04 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-19 | 2023-04-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-19 | 2023-03-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-19 | 2023-03-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-19 | 2023-03-27 | 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 | 2022-12-19 | 2023-03-27 | Y |
| Post nurse staffing information every day. | Health | 2022-12-19 | 2023-03-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-19 | 2023-03-27 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-05 | 2023-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-19 | 2023-01-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-19 | 2023-01-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-09 | 2022-09-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-09 | 2022-09-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-31 | 2022-09-27 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-04 | 2022-03-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-04 | 2022-03-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-04 | 2022-03-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-04 | 2022-03-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-04 | 2022-03-14 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-04 | 2022-03-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-02 | 2022-03-14 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Establish methods for sharing information. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-04 | 2022-03-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-04 | 2022-02-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-04 | 2022-01-18 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-10-04 | 2022-01-18 | N |
| 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 | 2021-10-04 | 2022-01-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | N |
| Provide appropriate foot care. | Health | 2021-10-04 | 2022-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-04 | 2022-01-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | N |
| Post nurse staffing information every day. | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-04 | 2022-01-18 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | N |
| Dispose of garbage and refuse properly. | Health | 2021-10-04 | 2022-01-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-04 | 2022-01-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-04 | 2022-01-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-04 | 2022-01-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-04 | 2022-01-18 | N |
| Keep all essential equipment working safely. | Health | 2021-10-04 | 2022-01-18 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2021-10-04 | 2022-01-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-10-04 | 2022-01-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-04 | 2022-01-18 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-04 | 2022-01-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-04 | 2022-01-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-04 | 2022-01-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-04 | 2022-01-18 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-04 | 2022-01-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-04 | 2022-01-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-04 | 2022-01-18 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-10-04 | 2022-01-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-04 | 2022-01-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-04 | 2022-01-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-04 | 2022-01-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | 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 | 2021-10-04 | 2022-01-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Meet other general requirements. | Fire Safety | 2021-10-04 | 2022-01-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-10-13 | 2020-11-13 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-10-13 | 2020-11-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-10-13 | 2020-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-10-13 | 2020-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-13 | 2020-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Post nurse staffing information every day. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-13 | 2020-11-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-13 | 2020-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-13 | 2020-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-13 | 2020-11-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-10-13 | 2020-11-13 | N |
| Use approved construction type or materials. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-10-13 | 2020-11-13 | 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 | 2020-10-13 | 2020-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-13 | 2020-11-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-04 | 2020-01-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-04 | 2019-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-04 | 2019-12-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-04 | 2019-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-04 | 2019-12-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-04 | 2019-12-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-11-04 | 2019-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-04 | 2019-12-16 | 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 | 2019-11-04 | 2019-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-04 | 2019-12-16 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-11-04 | 2019-12-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-04 | 2019-12-16 | N |
