Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Mar 20, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Severity G of L: actual harm, isolatedCorrected Mar 20, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedCorrected Mar 20, 2024
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 Feb 29, 2024
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 20, 2024
Provide a means of sharing information on occupancy/needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
Provide family notifications of emergency plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
Have properly located and lighted "Exit" signs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
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 Feb 22, 2024
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 1, 2024
Have elevators that firefighters can control in the event of a fire.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
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 Feb 29, 2024
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 Feb 29, 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 Feb 29, 2024
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 29, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 20, 2024
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 22, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 20, 2024
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 29, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 29, 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, patternCorrected Mar 20, 2024
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 Mar 20, 2024
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 20, 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, patternCorrected Mar 20, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 20, 2024
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 Mar 20, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 20, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 20, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 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, isolatedCorrected Mar 20, 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, isolatedFound during a complaint inspectionCorrected Mar 20, 2024
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 Mar 20, 2024
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 Mar 20, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
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 Mar 20, 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, isolatedCorrected Mar 20, 2024
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 Mar 20, 2024
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, isolatedFound during a complaint inspectionCorrected Mar 20, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 29, 2024
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 29, 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 Mar 20, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 20, 2024
