Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity K of L: immediate jeopardy, patternFound during a complaint inspectionCorrected Nov 19, 2024
Provide activities to meet all resident's needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 19, 2024
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.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 19, 2024
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 19, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 19, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 19, 2024
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.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
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.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 19, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
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, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
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, isolatedFound during a complaint inspectionCorrected Dec 16, 2024
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.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Observe each nurse aide's job performance and give regular training.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 16, 2024
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 Nov 19, 2024
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
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, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
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, isolatedFound during a complaint inspectionCorrected Nov 19, 2024
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 2025
Establish staff and initial training requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
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 Nov 19, 2024
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 Nov 19, 2024
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 Nov 19, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
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 Nov 19, 2024
