Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 19, 2019
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.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 19, 2019
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 9, 2019
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
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.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 19, 2019
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 19, 2019
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 9, 2019
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 19, 2019
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 9, 2019
