To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 18, 2023
Install proper backup exit lighting.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 18, 2023
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 Aug 18, 2023
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 Aug 18, 2023
Ensure the activities program is directed by a qualified professional.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Aug 18, 2023
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 F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Aug 18, 2023
Dispose of garbage and refuse properly.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Sep 25, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Keep all essential equipment working safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
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, patternFound during a complaint inspectionCorrected Aug 18, 2023
Honor the resident's right to manage his or her financial affairs.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
Provide activities to meet all resident's needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 18, 2023
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, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
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 Aug 18, 2023
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, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
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, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
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, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
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, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
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, isolatedFound during a complaint inspectionCorrected Aug 18, 2023
