Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Aug 1, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Aug 1, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Aug 1, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Jun 25, 2024
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 1, 2024
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 25, 2024
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 21, 2024
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 Jun 17, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 21, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Jun 25, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 25, 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 Aug 1, 2024
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 25, 2024
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 25, 2024
Have exits that are accessible at all times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 20, 2024
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 25, 2024
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 Jun 25, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 25, 2024
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 25, 2024
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 Jun 25, 2024
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 25, 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, isolatedFound during a complaint inspectionCorrected Jun 25, 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 Jun 25, 2024
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.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 25, 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 Jun 25, 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 Jun 25, 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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 1, 2024
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 24, 2024
Have restrictions on the use of portable space heaters.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
Have restrictions on the use of highly flammable decorations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
Have an enclosure around a vertical opening shaft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
Install proper backup exit lighting.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
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 Jun 25, 2024
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
Give residents a notice of rights, rules, services and charges.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 2024
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.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 25, 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 Jun 25, 2024
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity C of L: potential for minimal harm, widespreadCorrected Jun 25, 2024
