Deficiency Records for Park Avenue Healthcare and Wellness Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Park Avenue Healthcare and Wellness 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-08 | 2023-11-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-31 | 2023-11-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-31 | 2023-11-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-21 | 2023-10-15 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2023-09-15 | 2023-10-15 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-09-15 | 2023-10-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-15 | 2023-10-15 | 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 | 2023-09-15 | 2023-10-15 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-15 | 2023-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-15 | 2023-10-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-15 | 2023-10-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-15 | 2023-10-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-09-15 | 2023-10-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-15 | 2023-10-15 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-15 | 2023-10-15 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-15 | 2023-10-15 | Y |
| Help the resident make transportation arrangements to and from radiology services. | Health | 2023-09-15 | 2023-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-10-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-28 | 2023-10-15 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-28 | 2023-10-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-28 | 2023-10-15 | 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 | 2023-08-28 | 2023-10-15 | 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 | 2023-08-28 | 2023-10-15 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-08-28 | 2023-10-15 | 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 | 2023-08-28 | 2023-10-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-28 | 2023-10-15 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-28 | 2023-10-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-03 | 2023-09-25 | 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 | 2023-08-03 | 2023-09-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-03 | 2023-09-25 | 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 | 2023-08-03 | 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 | 2023-07-27 | 2023-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-27 | 2023-08-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-21 | 2023-08-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-19 | 2023-08-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-26 | 2023-05-26 | 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 | 2023-04-27 | 2023-05-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-27 | 2023-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-05-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-27 | 2023-05-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-10 | 2023-04-25 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-04-07 | 2023-04-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-24 | 2023-04-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-04-01 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-08 | 2023-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-04-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-08 | 2023-04-01 | 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 | 2023-03-08 | 2023-04-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-02 | 2023-02-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-02 | 2023-02-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-04 | 2023-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-04 | 2023-02-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-05 | 2023-02-03 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-12-03 | 2022-12-29 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-03 | 2022-12-29 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-12-03 | 2022-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2022-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-14 | Y |
| Post nurse staffing information every day. | Health | 2022-09-14 | 2022-10-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-31 | 2022-09-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-17 | 2022-09-12 | 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 | 2022-08-17 | 2022-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-08-19 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-06-10 | 2022-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-10 | 2022-07-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-10 | 2022-07-01 | Y |
| Provide appropriate foot care. | Health | 2022-02-11 | 2022-06-16 | 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 | 2022-02-11 | 2022-06-16 | 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 | 2022-02-11 | 2022-06-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-11 | 2022-06-14 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-06 | 2022-05-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-06 | 2022-05-20 | 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 | 2022-05-06 | 2022-05-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-08 | 2022-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-12 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-08 | 2022-05-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-15 | 2022-05-03 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-04-18 | 2022-04-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2022-04-25 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-05-26 | 2022-04-18 | 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 | 2022-03-18 | 2022-04-16 | Y |
| Post nurse staffing information every day. | Health | 2022-03-18 | 2022-04-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-18 | 2022-04-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-04-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-04 | 2022-04-14 | 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 | 2022-02-24 | 2022-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-03-14 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-02-22 | 2022-03-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-07 | 2022-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-10-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-08 | 2021-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-08 | 2021-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-16 | 2021-10-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-09-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-13 | 2021-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-07-27 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-06-18 | 2021-07-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-24 | 2021-07-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-24 | 2021-07-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-24 | 2021-07-02 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-05-24 | 2021-07-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-24 | 2021-07-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-24 | 2021-07-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-24 | 2021-07-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-05-24 | 2021-07-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-24 | 2021-07-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-24 | 2021-07-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-24 | 2021-07-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-07-02 | 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 | 2021-05-24 | 2021-07-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-24 | 2021-07-02 | 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 | 2021-05-24 | 2021-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-24 | 2021-07-02 | 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 | 2021-05-24 | 2021-07-02 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-05-24 | 2021-07-02 | 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 | 2021-05-24 | 2021-07-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-24 | 2021-07-02 | 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 | 2021-05-24 | 2021-07-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-24 | 2021-07-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-24 | 2021-07-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-24 | 2021-07-02 | 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 | 2021-05-24 | 2021-07-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-24 | 2021-07-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-24 | 2021-07-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-24 | 2021-07-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-24 | 2021-07-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-24 | 2021-07-02 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-19 | 2021-06-18 | 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 | 2021-05-19 | 2021-06-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-05-19 | 2021-06-18 | 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 | 2021-05-19 | 2021-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-05-19 | 2021-06-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-03 | 2021-06-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-25 | 2020-03-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-25 | 2020-03-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-25 | 2020-03-24 | 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 | 2020-02-25 | 2020-03-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-25 | 2020-03-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-25 | 2020-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-25 | 2020-03-24 | 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 | 2020-02-25 | 2020-03-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-25 | 2020-03-24 | N |
| Post nurse staffing information every day. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-25 | 2020-03-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-25 | 2020-03-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-25 | 2020-03-24 | N |
| Keep all essential equipment working safely. | Health | 2020-02-25 | 2020-03-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-25 | 2020-03-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-25 | 2020-03-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-25 | 2020-03-24 | 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 | 2020-02-25 | 2020-03-24 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-07 | 2019-03-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-07 | 2019-03-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-07 | 2019-03-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-07 | 2019-03-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-07 | 2019-03-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-07 | 2019-03-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-03-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-07 | 2019-03-26 | N |
| Post nurse staffing information every day. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-07 | 2019-03-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-07 | 2019-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-06 | 2019-03-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
