Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity J of L: immediate jeopardy, isolatedCorrected Oct 3, 2022
Keep all essential equipment working safely.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 24, 2022
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
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 Oct 3, 2022
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 24, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 24, 2022
Properly provide smoke detection systems in areas open to corridors.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
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 Aug 31, 2022
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 Aug 31, 2022
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
Install corridor and hallway doors that block smoke.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
Assure the security of all personal funds of residents deposited with the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 31, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
Observe each nurse aide's job performance and give regular training.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
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 Oct 3, 2022
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2022
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 Oct 3, 2022
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 31, 2022
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 Oct 3, 2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
Assure that each resident’s assessment is updated at least once every 3 months.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
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 Oct 3, 2022
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 Oct 3, 2022
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 24, 2022
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 Nov 24, 2022
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 Oct 3, 2022
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 Nov 24, 2022
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 3, 2022
Establish emergency prep training and testing.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 31, 2022
Establish staff and initial training requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 31, 2022
Conduct testing and exercise requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 31, 2022
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 31, 2022
Perform COVID19 testing on residents and staff.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
Conduct risk assessment and an All-Hazards approach.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 31, 2022
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 31, 2022
Meet Health Care Facilities Code mechanical requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 31, 2022
Provide or get specialized rehabilitative services as required for a resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
Provide or obtain dental services for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
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 Oct 3, 2022
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
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 Oct 3, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
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 Oct 3, 2022
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
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 Nov 24, 2022
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 Oct 3, 2022
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2022
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 24, 2022
