Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 12, 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, patternCorrected May 10, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 11, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 2024
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 2024
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 May 10, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 12, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 11, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 10, 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 Jun 20, 2024
Provide or obtain dental services for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 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, isolatedCorrected May 11, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 10, 2024
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 2024
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 May 10, 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 May 10, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 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 May 10, 2024
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 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 May 10, 2024
Implement a program that monitors antibiotic use.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 2024
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 12, 2024
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity B of L: potential for minimal harm, patternWaiver has been granted