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 L of L: immediate jeopardy, widespreadCorrected Jun 6, 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 Jun 6, 2022
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 6, 2022
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 6, 2022
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 May 10, 2022
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 6, 2022
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 Jun 6, 2022
Have properly installed hallway dispensers for alcohol-based hand rub.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 6, 2022
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 6, 2022
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 6, 2022
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 May 2, 2022
Install emergency lighting that can last at least 1 1/2 hours.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 6, 2022
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 6, 2022
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 6, 2022
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 2, 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 May 2, 2022
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, isolatedCorrected May 2, 2022
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 2, 2022
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 May 2, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 2, 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 May 2, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 2, 2022
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 6, 2022
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 2, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 2, 2022
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 May 2, 2022
