A list of the most recent deficiencies for Aventura at Terrace View. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-28 | 2024-01-30 | 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 | 2023-12-28 | 2024-01-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-28 | 2024-01-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-28 | 2024-01-30 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-28 | 2024-01-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2023-12-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2023-12-28 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-12-05 | 2023-12-28 | 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 | 2023-10-18 | 2023-11-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-18 | 2023-11-15 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-10-18 | 2023-11-15 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-10-18 | 2023-11-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-10-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-10-18 | 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 | 2023-02-15 | 2023-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-15 | 2023-07-11 | 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 | 2023-02-15 | 2023-07-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-15 | 2023-07-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-15 | 2023-07-11 | 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 | 2023-02-15 | 2023-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-15 | 2023-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-15 | 2023-07-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-15 | 2023-07-11 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-02-15 | 2023-07-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-15 | 2023-07-11 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-02-15 | 2023-07-11 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-15 | 2023-07-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-04 | 2023-06-14 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-27 | 2023-06-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-27 | 2023-06-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-27 | 2023-06-14 | 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 | 2023-04-27 | 2023-06-14 | 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 | 2023-04-27 | 2023-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-23 | 2023-06-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-23 | 2023-06-14 | Y |
| Post nurse staffing information every day. | Health | 2023-03-23 | 2023-06-14 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-23 | 2023-06-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-23 | 2023-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-15 | 2023-06-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-15 | 2023-06-14 | 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 | 2023-02-15 | 2023-06-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-15 | 2023-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-15 | 2023-06-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-15 | 2023-06-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-15 | 2023-06-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-15 | 2023-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-15 | 2023-06-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-15 | 2023-06-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-02-15 | 2023-06-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-15 | 2023-06-14 | 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 | 2023-02-15 | 2023-06-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-15 | 2023-06-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-15 | 2023-06-14 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-02-15 | 2023-06-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-02-15 | 2023-06-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-15 | 2023-06-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-15 | 2023-06-14 | 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 | 2023-02-15 | 2023-06-14 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-15 | 2023-06-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-15 | 2023-06-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-02-15 | 2023-06-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-02-15 | 2023-06-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-15 | 2023-06-14 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-15 | 2023-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-15 | 2023-06-14 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-02-15 | 2023-06-14 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-02-15 | 2023-06-14 | 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 | 2023-02-15 | 2023-06-14 | 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 | 2023-02-27 | 2023-04-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-27 | 2023-04-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-27 | 2023-04-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-27 | 2023-04-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-02-27 | 2023-04-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-27 | 2023-04-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-11-22 | 2023-01-10 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-22 | 2022-12-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-22 | 2022-12-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-22 | 2022-12-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-22 | 2022-12-20 | Y |
| Post nurse staffing information every day. | Health | 2022-10-17 | 2022-11-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-17 | 2022-11-22 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-10-17 | 2022-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-21 | 2022-11-22 | 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 | 2022-09-21 | 2022-11-22 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-21 | 2022-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-21 | 2022-11-22 | 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 | 2022-09-07 | 2022-11-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-11-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-07 | 2022-11-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-12 | 2022-11-22 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-12 | 2022-11-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-12 | 2022-11-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-09 | 2022-07-26 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-09 | 2022-07-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-09 | 2022-07-26 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-06-09 | 2022-07-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-09 | 2022-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-09 | 2022-07-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-09 | 2022-07-26 | 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 | 2022-06-09 | 2022-07-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-09 | 2022-07-26 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-09 | 2022-07-26 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-09 | 2022-07-26 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-09 | 2022-07-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-28 | 2022-07-26 | 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 | 2022-04-28 | 2022-07-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-28 | 2022-07-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-28 | 2022-07-26 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-28 | 2022-07-26 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-28 | 2022-07-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-04 | 2022-07-26 | 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 | 2022-03-04 | 2022-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-04 | 2022-07-26 | 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 | 2022-03-04 | 2022-07-26 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-05-19 | 2022-06-09 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-28 | 2022-06-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-06-09 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-04-28 | 2022-06-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-06-09 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-04-28 | 2022-06-09 | 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 | 2022-04-28 | 2022-06-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-28 | 2022-06-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-28 | 2022-06-09 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-04-28 | 2022-06-09 | 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 | 2022-03-04 | 2022-06-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-04 | 2022-06-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-04 | 2022-05-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-04 | 2022-04-28 | 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 | 2022-03-04 | 2022-04-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-04 | 2022-04-28 | 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 | 2022-03-04 | 2022-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-04-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-04 | 2022-04-28 | N |
| Post nurse staffing information every day. | Health | 2022-03-04 | 2022-04-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-04 | 2022-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-04-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-04 | 2022-04-28 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-03-09 | 2022-04-22 | 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 | 2022-03-09 | 2022-04-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-03-09 | 2022-04-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-03-09 | 2022-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-09 | 2022-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-09 | 2022-04-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-09 | 2022-04-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-15 | 2021-11-01 | 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 | 2021-09-15 | 2021-11-01 | 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 | 2021-09-15 | 2021-11-01 | 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 | 2021-04-30 | 2021-06-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-30 | 2021-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-30 | 2021-06-02 | 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 | 2021-04-30 | 2021-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-30 | 2021-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-30 | 2021-06-02 | 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 | 2021-04-30 | 2021-06-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-30 | 2021-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-30 | 2021-06-02 | N |
| Use approved construction type or materials. | Fire Safety | 2021-04-14 | 2021-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-14 | 2021-04-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-14 | 2021-04-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-14 | 2021-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-05 | Not Fixed | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-15 | Not Fixed | 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 | 2023-11-15 | Not Fixed | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-15 | Not Fixed | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-15 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-15 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-15 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | Not Fixed | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-15 | Not Fixed | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-15 | Not Fixed | Y |
| Keep all essential equipment working safely. | Health | 2023-11-15 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-18 | Not Fixed | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-18 | Not Fixed | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-04-27 | Not Fixed | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-27 | Not Fixed | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-27 | Not Fixed | Y |
