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 Mar 1, 2024
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 Mar 1, 2024
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 Mar 1, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 1, 2024
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 1, 2024
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 1, 2024
Have exits that are accessible at all times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 1, 2024
Have properly located and lighted "Exit" signs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 1, 2024
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 Mar 1, 2024
Assure the security of all personal funds of residents deposited with the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 1, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 1, 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 Mar 1, 2024
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 1, 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 21, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 1, 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 Mar 1, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 1, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 1, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 1, 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 1, 2024
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 1, 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 1, 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 Mar 1, 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 Mar 1, 2024
