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 Aug 13, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 2024
Install corridor and hallway doors that block smoke.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 2024
Have properly installed electrical wiring and gas equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 2024
Install properly constructed and protected linen or trash chutes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 2024
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 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 Aug 13, 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 Aug 13, 2024
Ensure proper usage of power strips and extension cords.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 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, widespreadCorrected Aug 13, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 13, 2024
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 Aug 13, 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 Aug 13, 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 Aug 13, 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 Aug 13, 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, patternFound during a complaint inspectionCorrected Aug 13, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 13, 2024
Have restrictions on the use of portable space heaters.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 13, 2024
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 13, 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 Aug 13, 2024
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 13, 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, isolatedCorrected Aug 13, 2024
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 13, 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, isolatedCorrected Aug 13, 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 Aug 13, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 13, 2024
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 Aug 13, 2024
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 13, 2024
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, isolatedFound during a complaint inspectionCorrected Aug 13, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 13, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 13, 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 Aug 13, 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, isolatedFound during a complaint inspectionCorrected Aug 13, 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 Aug 13, 2024
Implement a program that monitors antibiotic use.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 13, 2024
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 Aug 13, 2024
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 Aug 13, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 13, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 13, 2024
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 13, 2024
