CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Friendship Rehab and Health
View the most recent health deficiencies and inspection results for Friendship Rehab and Health. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Friendship Rehab and Health. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2026-03-13 | 2026-05-11 | 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 | 2026-03-13 | 2026-05-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2026-03-13 | 2026-05-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2026-03-13 | 2026-04-23 | N |
| Dispose of garbage and refuse properly. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2026-03-13 | 2026-04-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2026-03-13 | 2026-04-23 | N |
| 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 | 2026-03-13 | 2026-04-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2026-03-13 | 2026-04-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2026-03-13 | 2026-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2026-03-13 | 2026-04-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2026-03-13 | 2026-04-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-03-13 | 2026-04-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-03-13 | 2026-04-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-03-13 | 2026-04-23 | 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 | 2026-03-13 | 2026-04-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2026-03-13 | 2026-04-23 | 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 | 2026-03-13 | 2026-04-23 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-03-13 | 2026-04-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2026-03-13 | 2026-04-23 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2026-03-13 | 2026-04-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2026-03-13 | 2026-04-23 | N |
| Keep all essential equipment working safely. | Health | 2026-03-13 | 2026-04-23 | 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 | 2026-03-13 | 2026-04-23 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2026-03-13 | 2026-04-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-12-29 | 2026-01-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-12-05 | 2025-12-19 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2025-12-04 | 2025-12-12 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-12-04 | 2025-12-12 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2025-12-04 | 2025-12-12 | Y |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-12-04 | 2025-12-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-12-04 | 2025-12-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-12-04 | 2025-12-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-12-04 | 2025-12-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-12-04 | 2025-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-12-05 | 2025-11-24 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2025-08-07 | 2025-09-02 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2025-08-07 | 2025-09-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-08-07 | 2025-09-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-07 | 2025-09-02 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2025-08-07 | 2025-09-02 | 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 | 2025-08-07 | 2025-09-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-08-07 | 2025-09-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-08-07 | 2025-09-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-07 | 2025-09-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-08-07 | 2025-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-07 | 2025-07-26 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2025-06-11 | 2025-06-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-02-14 | 2025-05-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-04-24 | 2025-05-07 | 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 | 2025-04-24 | 2025-05-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-02-14 | 2025-05-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-02-14 | 2025-05-02 | Y |
| 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 | 2025-02-14 | 2025-05-02 | N |
| Provide activities to meet all resident's needs. | Health | 2025-04-03 | 2025-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-04-03 | 2025-04-18 | Y |
| Help the resident make transportation arrangements to and from radiology services. | Health | 2025-04-03 | 2025-04-18 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2025-04-03 | 2025-04-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2025-02-14 | 2025-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-14 | 2025-03-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-02-14 | 2025-03-13 | 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 | 2025-02-14 | 2025-03-13 | 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 | 2025-02-14 | 2025-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-02-14 | 2025-03-13 | N |
| Respond appropriately to all alleged violations. | Health | 2025-02-14 | 2025-03-13 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2025-02-14 | 2025-03-13 | 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 | 2025-02-14 | 2025-03-13 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-02-14 | 2025-03-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-02-14 | 2025-03-13 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-02-14 | 2025-03-13 | N |
| Keep all essential equipment working safely. | Health | 2025-02-14 | 2025-03-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2025-02-14 | 2025-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-02-14 | 2025-03-13 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2025-02-14 | 2025-03-13 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2025-02-14 | 2025-03-13 | 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 (including nights and weekends) and emergencies. | Health | 2025-02-14 | 2025-03-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-02-14 | 2025-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-02-14 | 2025-03-13 | N |
| Provide or obtain dental services for each resident. | Health | 2025-02-14 | 2025-03-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2025-02-14 | 2025-03-13 | N |
| 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 | 2025-02-14 | 2025-03-13 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2025-02-14 | 2025-03-13 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-02-14 | 2025-03-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-02-14 | 2025-03-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-02-14 | 2025-03-13 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-02-14 | 2025-03-13 | 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 | 2025-02-14 | 2025-03-13 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2025-02-14 | 2025-03-13 | 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 | 2025-02-14 | 2025-03-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2025-02-14 | 2025-02-21 | 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 | 2025-02-14 | 2025-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2025-02-14 | 2025-02-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-02-14 | 2025-02-21 | 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 | 2025-01-09 | 2025-01-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-12-12 | 2024-12-27 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-12-12 | 2024-12-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-12 | 2024-12-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-12-12 | 2024-12-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-12-12 | 2024-12-27 | Y |
| 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 | 2024-11-07 | 2024-11-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-07 | 2024-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-11-07 | 2024-11-22 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-10-17 | 2024-10-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-10-11 | 2024-10-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-10-11 | 2024-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-10-11 | 2024-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-25 | 2024-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-04 | 2024-09-20 | 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 | 2024-09-04 | 2024-09-20 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-09-04 | 2024-09-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-09-04 | 2024-09-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-07-24 | 2024-08-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-24 | 2024-08-08 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-07-24 | 2024-08-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-24 | 2024-08-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-07-24 | 2024-08-08 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-06-27 | 2024-08-02 | Y |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-07-02 | 2024-08-02 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-07-02 | 2024-08-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-02 | 2024-08-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-02 | 2024-08-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-02 | 2024-08-02 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-02 | 2024-08-02 | 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 | 2024-07-02 | 2024-08-02 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-27 | 2024-07-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-12 | 2024-06-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-13 | 2024-05-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-03-13 | 2024-05-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-13 | 2024-05-08 | 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 | 2024-03-13 | 2024-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-13 | 2024-05-08 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-13 | 2024-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-13 | 2024-05-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-13 | 2024-05-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-13 | 2024-05-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-13 | 2024-05-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-13 | 2024-05-08 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-03-13 | 2024-05-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-13 | 2024-05-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-13 | 2024-05-08 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-13 | 2024-05-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-03-13 | 2024-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-13 | 2024-05-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-13 | 2024-05-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-13 | 2024-05-08 | 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 | 2024-03-13 | 2024-05-08 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2024-03-13 | 2024-05-08 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-03-13 | 2024-05-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-10 | 2024-05-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-13 | 2024-05-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-13 | 2024-04-16 | N |
| Keep all essential equipment working safely. | Health | 2023-11-28 | 2023-12-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-28 | 2023-12-27 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-11-28 | 2023-12-27 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-11-28 | 2023-12-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-28 | 2023-12-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-28 | 2023-12-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-19 | 2023-11-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-19 | 2023-11-15 | Y |
| 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 | 2023-10-19 | 2023-11-15 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-19 | 2023-11-15 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-19 | 2023-11-15 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-08-22 | 2023-09-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-22 | 2023-09-27 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-08-22 | 2023-09-27 | Y |
| Report COVID19 data to residents and families. | Health | 2023-09-06 | 2023-09-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-06 | 2023-09-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-06 | 2023-09-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-04-30 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-30 | Not Fixed | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-04-30 | Not Fixed | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-08-27 | Not Fixed | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2025-08-27 | Not Fixed | Y |