Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity G of L: actual harm, isolatedCorrected Nov 19, 2022
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity G of L: actual harm, isolatedCorrected Nov 19, 2022
Provide enough food/fluids to maintain a resident's health.
Severity G of L: actual harm, isolatedCorrected Dec 30, 2022
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2022
Perform COVID19 testing on residents and staff.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 30, 2022
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 Nov 19, 2022
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2022
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2022
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2022
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 30, 2022
Report COVID19 data to residents and families.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2022
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 30, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 30, 2022
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 Dec 30, 2022
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 Dec 30, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2022
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 Dec 30, 2022
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2022
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 20, 2022
Ensure staff are vaccinated for COVID-19
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2022
Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2022
Implement emergency and standby power systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 18, 2022
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
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 Nov 19, 2022
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 Nov 19, 2022
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
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 Dec 30, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 30, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
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 Nov 19, 2022
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, isolatedCorrected Nov 19, 2022
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
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 Dec 30, 2022
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2022
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 Nov 19, 2022
