Deficiency Records for The Rehabilitation Center of Santa Monica
Updated as of April 01, 2024
A list of the most recent deficiencies for The Rehabilitation Center of Santa Monica. 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? |
|---|---|---|---|---|
| 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 | 2024-02-27 | 2024-03-24 | 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 | 2024-01-08 | 2024-03-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-08 | 2024-03-11 | 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 | 2024-01-08 | 2024-03-11 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-01 | 2024-02-22 | 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 | 2024-02-01 | 2024-02-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-02-01 | 2024-02-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-25 | 2024-02-18 | N |
| 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 | 2024-01-25 | 2024-02-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-25 | 2024-02-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-25 | 2024-02-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-25 | 2024-02-18 | 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 | 2024-01-25 | 2024-02-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-25 | 2024-02-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-18 | 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 | 2024-01-25 | 2024-02-18 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-01-25 | 2024-02-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-25 | 2024-02-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-25 | 2024-02-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-25 | 2024-02-18 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-01-25 | 2024-02-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-25 | 2024-02-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-02-18 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-01-25 | 2024-02-18 | N |
| Keep all essential equipment working safely. | Health | 2024-01-25 | 2024-02-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-25 | 2024-02-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-16 | 2024-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-01-29 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-08 | 2024-01-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-08 | 2024-01-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-08 | 2024-01-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-08 | 2024-01-28 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-08 | 2024-01-28 | Y |
| 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 | 2024-01-08 | 2024-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-08 | 2024-01-28 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-08 | 2024-01-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-12 | 2024-01-01 | 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 | 2023-12-12 | 2024-01-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-12 | 2024-01-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-12 | 2024-01-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-07 | 2023-11-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-07 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-07 | 2023-11-30 | 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 | 2023-11-07 | 2023-11-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-07 | 2023-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-11-30 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-31 | 2023-11-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-01 | 2023-11-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-16 | 2023-10-27 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-09-23 | 2023-10-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-27 | 2023-10-13 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-21 | 2023-08-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-22 | 2023-06-16 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-04-23 | 2023-05-11 | 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 | 2023-04-23 | 2023-05-11 | Y |
| 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 | 2023-04-23 | 2023-05-11 | 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 | 2023-04-23 | 2023-05-11 | 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 | 2023-04-24 | 2023-05-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-10 | 2023-03-31 | N |
| 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 | 2023-03-10 | 2023-03-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-03-10 | 2023-03-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-10 | 2023-03-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-10 | 2023-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-03-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-10 | 2023-03-31 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-10 | 2023-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-10 | 2023-03-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-10 | 2023-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-10 | 2023-03-31 | 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 | 2023-03-10 | 2023-03-31 | 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 | 2023-03-10 | 2023-03-31 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-03-10 | 2023-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-10 | 2023-03-31 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-03-10 | 2023-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-10 | 2023-03-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-10 | 2023-03-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-10 | 2023-03-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-10 | 2023-03-31 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-10 | 2023-03-31 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-10 | 2023-03-31 | 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 | 2023-03-10 | 2023-03-31 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-10 | 2023-03-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-10 | 2023-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-03-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-10 | 2023-03-31 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-03-10 | 2023-03-31 | 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 | 2023-03-10 | 2023-03-31 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-10 | 2023-03-31 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-09 | 2023-03-31 | 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 | 2023-03-09 | 2023-03-31 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-09 | 2023-03-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-22 | 2023-03-04 | Y |
| 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 | 2023-02-22 | 2023-03-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-30 | 2023-02-11 | 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 | 2023-01-30 | 2023-02-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-30 | 2023-02-11 | 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 | 2023-01-30 | 2023-02-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-18 | 2023-01-29 | 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 | 2022-10-13 | 2022-10-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-06 | 2022-09-21 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-09-06 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-07 | 2022-09-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-24 | 2022-07-08 | Y |
| 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 | 2022-05-17 | 2022-05-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-20 | 2022-05-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-02 | 2022-04-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-02 | 2022-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-30 | 2022-04-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-29 | 2022-04-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-18 | 2022-03-28 | Y |
| Post nurse staffing information every day. | Health | 2022-03-16 | 2022-03-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-12 | 2022-03-22 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-03-04 | 2022-03-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-03-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-04 | 2022-03-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-03-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-14 | 2022-02-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-02-14 | 2022-02-28 | 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 | 2022-02-14 | 2022-02-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-23 | 2022-02-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-21 | 2022-02-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-21 | 2022-02-01 | Y |
| Provide immediate access to any resident. | Health | 2022-01-07 | 2022-01-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-07 | 2022-01-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-07 | 2022-01-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-06 | 2022-01-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-06 | 2022-01-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-06 | 2022-01-18 | Y |
| 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 | 2021-11-14 | 2021-12-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-08 | 2021-11-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-28 | 2021-11-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-28 | 2021-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2021-11-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-09 | 2021-10-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-18 | 2021-09-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-07-16 | 2021-07-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-16 | 2021-07-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-14 | 2021-06-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-06-29 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-06-18 | 2021-06-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-18 | 2021-06-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-15 | 2021-06-28 | 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 | 2021-05-31 | 2021-06-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-09 | 2021-04-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-01 | 2021-04-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-20 | 2019-06-20 | 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 | 2019-05-20 | 2019-06-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-05-20 | 2019-06-20 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-05-20 | 2019-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-20 | 2019-06-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-20 | 2019-06-20 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-05-23 | 2019-06-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-23 | 2019-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-23 | 2019-06-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-23 | 2019-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-23 | 2019-06-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-23 | 2019-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-23 | 2019-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-08 | Not Fixed | Y |
