Deficiency Records for Glen Brook Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Glen Brook Rehabilitation and 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-06 | 2024-03-28 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-02-06 | 2024-03-28 | 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 | 2024-02-06 | 2024-03-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-06 | 2024-03-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-03-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-06 | 2024-03-28 | 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 | 2024-02-06 | 2024-03-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-06 | 2024-03-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-06 | 2024-03-28 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-08 | 2024-02-06 | 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 | 2023-12-08 | 2024-02-06 | 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 | 2023-12-08 | 2024-02-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-08 | 2024-02-06 | 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 | 2023-12-08 | 2024-02-06 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-12-08 | 2024-02-06 | 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 | 2023-12-08 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-08 | 2024-02-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-08 | 2024-02-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-08 | 2024-02-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-08 | 2024-02-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-08 | 2024-02-06 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-21 | 2024-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-08 | 2024-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-08 | 2024-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-08 | 2024-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-08 | 2024-01-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-08 | 2024-01-23 | 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 | 2023-12-08 | 2024-01-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-08 | 2024-01-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-21 | 2023-09-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-21 | 2023-09-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-21 | 2023-09-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-07-21 | 2023-09-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-21 | 2023-09-12 | 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 | 2023-07-21 | 2023-09-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-21 | 2023-09-12 | 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 | 2023-07-21 | 2023-09-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-21 | 2023-09-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-21 | 2023-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-21 | 2023-09-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-21 | 2023-09-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-07-21 | 2023-09-12 | 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 | 2023-07-21 | 2023-09-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-21 | 2023-09-12 | 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 | 2023-07-21 | 2023-09-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-21 | 2023-09-12 | 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 | 2023-07-21 | 2023-09-12 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-07-21 | 2023-09-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-21 | 2023-09-12 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-07-21 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-21 | 2023-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-10 | 2023-08-15 | 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 | 2023-07-10 | 2023-08-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-10 | 2023-08-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-10 | 2023-08-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-10 | 2023-08-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-10 | 2023-08-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-27 | 2023-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-27 | 2023-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-27 | 2023-04-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-27 | 2023-04-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-27 | 2023-03-22 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-27 | 2023-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-27 | 2023-03-22 | 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 | 2023-01-27 | 2023-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-27 | 2023-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-27 | 2023-03-22 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-01-27 | 2023-03-22 | 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 | 2023-01-27 | 2023-03-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-08-10 | 2022-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-10 | 2022-08-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-10 | 2022-08-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-22 | 2022-08-25 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-07-22 | 2022-08-25 | 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 | 2022-07-22 | 2022-08-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-22 | 2022-08-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-22 | 2022-08-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-09 | 2022-01-14 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-12-09 | 2022-01-14 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-09 | 2022-01-14 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-12-09 | 2022-01-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-14 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-21 | 2021-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-21 | 2021-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-21 | 2021-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-21 | 2021-10-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-21 | 2021-10-14 | 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 | 2021-09-21 | 2021-10-14 | Y |
| 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 | 2021-09-21 | 2021-10-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-21 | 2021-10-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-21 | 2021-10-14 | 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 | 2021-09-21 | 2021-10-14 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-09-21 | 2021-10-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-21 | 2021-10-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-21 | 2021-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-14 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-09-21 | 2021-10-14 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-21 | 2021-10-14 | Y |
| 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 | 2021-09-21 | 2021-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-19 | 2021-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-19 | 2021-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-10-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-19 | 2021-10-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-10-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-19 | 2021-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-10-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-29 | 2021-10-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-29 | 2021-10-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-19 | 2021-09-21 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-08-19 | 2021-09-21 | Y |
| Provide or obtain dental services for each resident. | Health | 2021-08-19 | 2021-09-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-08-19 | 2021-09-21 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-08-19 | 2021-09-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-06-29 | 2021-09-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-29 | 2021-08-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-29 | 2021-08-19 | 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 | 2021-06-29 | 2021-08-19 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-06-29 | 2021-08-19 | 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 | 2021-06-29 | 2021-08-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-29 | 2021-08-19 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-29 | 2021-08-19 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-06-29 | 2021-08-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-29 | 2021-08-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-29 | 2021-08-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-27 | 2021-08-19 | 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 | 2021-05-27 | 2021-08-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-27 | 2021-08-19 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-05-27 | 2021-06-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-27 | 2021-06-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-27 | 2021-06-29 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-05-27 | 2021-06-29 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-05-27 | 2021-06-29 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-27 | 2021-06-29 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-05-27 | 2021-06-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-27 | 2021-06-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-05-27 | 2021-06-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-27 | 2021-06-29 | Y |
| Report COVID19 data to residents and families. | Health | 2021-05-27 | 2021-06-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-27 | 2021-06-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-21 | 2021-06-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-21 | 2021-05-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-21 | 2021-05-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-21 | 2021-05-27 | 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 | 2021-04-21 | 2021-05-27 | Y |
| Post nurse staffing information every day. | Health | 2021-04-21 | 2021-05-27 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-04-21 | 2021-05-27 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-21 | 2021-05-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-21 | 2021-05-27 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-04-21 | 2021-05-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-06 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-06 | Not Fixed | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-06 | 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 | 2023-06-22 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-22 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-22 | Not Fixed | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-22 | Not Fixed | Y |
