Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Jan 25, 2025
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Jan 25, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Jan 25, 2025
Provide and implement an infection prevention and control program.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Jan 25, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Jan 25, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Jan 25, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Jan 25, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jan 25, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity G of L: actual harm, isolatedCorrected Jan 25, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity G of L: actual harm, isolatedCorrected Jan 25, 2025
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 17, 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, widespreadFound during a complaint inspectionCorrected Jan 25, 2025
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 25, 2025
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 Dec 17, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 17, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Jan 25, 2025
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Have restrictions on the use of portable space heaters.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 25, 2025
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 Jan 25, 2025
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 16, 2025
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 Jan 25, 2025
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 Jan 25, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 17, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 25, 2025