| Survey Date | Inspection Type | Track ID | Deficiency | Severity and Scope | Class | Requirement Description | Correction Date |
| 01/21/2025 | Complaint | 9C04 | None | None | None | NoneNone | None |
| 01/25/2024 | Standard | FMMH | None | None | None | NoneNone | None |
| 01/24/2024 | Fire/Life/Safety | FMMH | K0355 | D | 3 | PORTABLE FIRE EXTINGUISHERSPortable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, 9.9, and NFPA 10
| 02/25/2024 |
| 01/24/2024 | Fire/Life/Safety | FMMH | K0521 | D | 3 | HVACHVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
| 02/25/2024 |
| 01/24/2024 | Fire/Life/Safety | FMMH | K0761 | D | 3 | MAINTENANCE INSPECTION & TESTING - DOORSFire door assemblies shall be installed, inspected, tested, and maintained in accordance with NFPA 80.
All fire door assemblies shall be labeled.
Labels on fire door assemblies shall be maintained in a legible condition. In existing installations, steel door frames without a label shall be permitted where approved by the authority having jurisdiction. Unless otherwise specified, fire doors shall be self-closing or automatic-closing.
Doors, other than those listed in 8.2.2.4 and 8.3.3.3.1, that are required to be self-closing or automatic closing shall comply with all of the following:
(1) Door assemblies shall be inspected annually.
(2) Doors shall be operated to confirm full closure.
(3) Parts found to be damaged or inoperative shall be replaced.
(4) Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.
(5) Blocking or wedging of doors in the open position shall be prohibited.
(6) Self-closing and automatic-closing devices shall be kept in working condition at all times.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 4.6.12.1, 8.3.3.3 through 8.3.3.3.5, 8.5.4.3, 8.5.4, 8.7.1.3, 8.8 (NFPA 101)
5.2, 5.2.3 (NFPA 80)
| 02/25/2024 |
| 11/01/2023 | Fire/Life/Safety | 2EYK | None | None | None | NoneNone | None |
| 09/25/2022 | Fire/Life/Safety | GP7Z | None | None | None | NoneNone | None |
| 08/24/2022 | Fire/Life/Safety | OQOF | None | None | None | NoneNone | None |
| 01/14/2022 | Standard | XYG7 | F0550 | D | | RESIDENT RIGHTS/EXERCISE OF RIGHTS§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. | 02/14/2022 |
| 01/14/2022 | Standard | XYG7 | F0849 | D | | HOSPICE SERVICES§483.70(o) Hospice services.
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.
§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.
§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreem | 02/14/2022 |
|
|
