Have enough backup water supply for essential areas of the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
Keep all essential equipment working safely.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
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, widespreadCorrected Jan 31, 2019
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
Meet other general requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 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 Apr 5, 2019
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 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 Apr 5, 2019
Ensure each resident receives an accurate assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
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.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 31, 2019
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 2019
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 2019
Honor each resident's preferences, choices, values and beliefs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 2019
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, patternCorrected Jan 31, 2019
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2019
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 2019
Ensure that residents are free from significant medication errors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 2019
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 31, 2019
Meet requirements for the use of electrical equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2019
Prepare residents for a safe transfer or discharge from the nursing home.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 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 Jan 31, 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 Jan 31, 2019
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 Jan 31, 2019
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 2019
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 Apr 5, 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 Apr 5, 2019
Have exits that are accessible at all times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2019
Install proper backup exit lighting.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2019
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2019
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, isolatedCorrected Jan 31, 2019
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 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 Jan 31, 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 Jan 31, 2019
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 2019
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 31, 2019
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity C of L: potential for minimal harm, widespreadCorrected Jan 31, 2019
