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 Nov 4, 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 Nov 18, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 18, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 18, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 4, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 4, 2024
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 Nov 4, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 4, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 4, 2024
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 4, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Provide a written emergency evacuation plan.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 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 Nov 14, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Have an enclosure around a vertical opening shaft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Implement emergency and standby power systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Establish emergency prep training and testing.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Establish policies and procedures including evacuation.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 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 Nov 4, 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 Nov 4, 2024
Provide activities to meet all resident's needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 4, 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 Nov 4, 2024
List the names and contact information of those in the facility.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 14, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 4, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 4, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 4, 2024
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 4, 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 Nov 4, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 4, 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 Nov 4, 2024
Install emergency lighting that can last at least 1 1/2 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 14, 2024
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 14, 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 Nov 14, 2024
Meet requirements for the installation and maintenance of electrical systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 14, 2024
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 14, 2024
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 14, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 4, 2024
Have approved installation, maintenance and testing program for fire alarm systems.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 14, 2024