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 Jun 10, 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 Jun 10, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 10, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 10, 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 Jun 10, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jun 10, 2024
Respond appropriately to all alleged violations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 10, 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 Jun 10, 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 Jun 10, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 10, 2024
Provide enough food/fluids to maintain a resident's health.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 10, 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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jun 10, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jun 10, 2024
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 8, 2024
Have approved installation, maintenance and testing program for fire alarm systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 2024
Have simulated fire drills held at unexpected times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 8, 2024
Ensure that testing and maintenance of electrical equipment is performed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 24, 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 Jun 10, 2024
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 24, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 8, 2024
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 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, isolatedFound during a complaint inspectionCorrected Jun 10, 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 Jun 10, 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 Jun 10, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 10, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 10, 2024
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 8, 2024
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 8, 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 Jun 10, 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 Jun 10, 2024