Deficiency Records for Summit's Trace Healthcare Center
Updated as of May 01, 2023
This is not the most recent data for Summit's Trace Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Summit's Trace Healthcare Center. 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 be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-01 | 2023-03-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-01 | 2023-03-02 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-02-01 | 2023-03-02 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-12-30 | 2023-03-02 | 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 | 2022-12-30 | 2023-03-02 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-30 | 2023-03-02 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-02-01 | 2023-02-27 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-02-01 | 2023-02-27 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-01 | 2023-01-31 | 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 | 2022-12-30 | 2023-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-30 | 2023-01-30 | 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 | 2022-12-30 | 2023-01-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-30 | 2023-01-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-30 | 2023-01-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-30 | 2023-01-30 | Y |
| Keep all essential equipment working safely. | Health | 2022-12-30 | 2023-01-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-31 | 2022-11-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-31 | 2022-11-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-31 | 2022-11-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-29 | 2022-11-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-29 | 2022-11-29 | 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 | 2022-08-29 | 2022-11-29 | 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 | 2022-08-29 | 2022-11-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-29 | 2022-11-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-29 | 2022-10-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-29 | 2022-10-13 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-29 | 2022-10-13 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-08-29 | 2022-10-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-29 | 2022-10-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-29 | 2022-10-13 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-08-29 | 2022-10-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-29 | 2022-10-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-29 | 2022-10-13 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-29 | 2022-10-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-29 | 2022-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-29 | 2022-10-13 | 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 | 2022-08-29 | 2022-10-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-29 | 2022-10-13 | 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 | 2022-08-29 | 2022-10-13 | 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 | 2022-08-29 | 2022-10-13 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-29 | 2022-10-13 | 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 | 2022-08-29 | 2022-10-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-29 | 2022-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-29 | 2022-10-13 | 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 | 2022-08-29 | 2022-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-10-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-29 | 2022-10-13 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-01 | 2022-10-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-08 | 2022-07-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-08 | 2022-07-26 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-03-14 | 2022-07-15 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-14 | 2022-07-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-17 | 2022-04-27 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-03-17 | 2022-04-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-03-17 | 2022-04-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-17 | 2022-04-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-27 | N |
| Provide or obtain dental services for each resident. | Health | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | N |
| 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 | 2022-03-17 | 2022-04-27 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-03-17 | 2022-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-04-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-17 | 2022-04-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-17 | 2022-04-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-17 | 2022-04-27 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-17 | 2022-04-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-17 | 2022-04-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-17 | 2022-04-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-17 | 2022-04-27 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-14 | 2022-04-27 | 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 | 2022-03-14 | 2022-04-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-14 | 2022-04-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-17 | 2022-04-22 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-17 | 2022-04-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-21 | 2022-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-02-10 | 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 | 2022-01-21 | 2022-02-10 | 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 | 2022-01-21 | 2022-02-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-21 | 2022-02-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-21 | 2022-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-02-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-27 | 2022-02-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-27 | 2022-02-10 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-01-11 | 2022-02-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-10 | 2021-09-18 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-09-10 | 2021-09-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-09-18 | 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 | 2021-08-20 | 2021-09-18 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-07-16 | 2021-09-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-16 | 2021-09-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-16 | 2021-09-18 | 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 | 2021-07-16 | 2021-09-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-16 | 2021-09-18 | 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 | 2021-07-16 | 2021-09-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-16 | 2021-09-18 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-07-16 | 2021-09-18 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-16 | 2021-09-18 | 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 | 2021-07-16 | 2021-09-18 | 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 | 2021-07-16 | 2021-09-18 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-07-16 | 2021-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-16 | 2021-09-18 | 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 | 2021-07-16 | 2021-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-16 | 2021-09-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-16 | 2021-09-18 | 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 | 2021-07-16 | 2021-09-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-16 | 2021-09-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-16 | 2021-09-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-16 | 2021-09-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-16 | 2021-09-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-16 | 2021-09-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-16 | 2021-09-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-16 | 2021-09-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-16 | 2021-09-18 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-01 | 2021-09-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-02 | 2021-06-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-02 | 2021-06-08 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-06-02 | 2021-06-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-02 | 2021-06-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-02 | 2021-06-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-14 | 2021-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-14 | 2021-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-14 | 2021-06-08 | Y |
| Provide appropriate foot care. | Health | 2021-04-14 | 2021-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-14 | 2021-06-08 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-04-14 | 2021-06-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-14 | 2021-06-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-14 | 2021-06-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-14 | 2021-06-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-14 | 2021-06-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-19 | 2021-06-08 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-03-19 | 2021-06-08 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-03-19 | 2021-06-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-19 | 2021-06-08 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-04 | 2021-06-08 | 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 | 2021-03-04 | 2021-06-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-04 | 2021-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-04 | 2021-06-08 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-03-04 | 2021-06-08 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-03-04 | 2021-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-04 | 2021-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-04 | 2021-06-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-04 | 2021-06-08 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-03-04 | 2021-06-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-04 | 2021-06-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-01-27 | 2021-06-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-01-12 | 2021-06-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-12 | 2021-06-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-24 | 2021-06-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2020-10-13 | 2020-11-06 | Y |
| Provide immediate access to any resident. | Health | 2020-10-13 | 2020-11-06 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-10-13 | 2020-11-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-10-13 | 2020-11-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-13 | 2020-11-06 | Y |
| Provide activities to meet all resident's needs. | Health | 2020-10-13 | 2020-11-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-13 | 2020-11-06 | 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 | 2020-10-13 | 2020-11-06 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-10-13 | 2020-11-06 | Y |
| Post nurse staffing information every day. | Health | 2020-10-13 | 2020-11-06 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-10-13 | 2020-11-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-13 | 2020-11-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-10-13 | 2020-11-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-13 | 2020-11-06 | Y |
| Keep all essential equipment working safely. | Health | 2020-10-13 | 2020-11-06 | Y |
