Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity J of L: immediate jeopardy, isolatedCorrected Feb 27, 2020
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity G of L: actual harm, isolatedCorrected Feb 27, 2020
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedCorrected Feb 27, 2020
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Severity G of L: actual harm, isolatedCorrected Feb 27, 2020
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 Feb 27, 2020
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 Feb 27, 2020
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 Feb 27, 2020
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, patternCorrected Feb 27, 2020
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, patternCorrected Feb 27, 2020
Respond appropriately to all alleged violations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Prepare residents for a safe transfer or discharge from the nursing home.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
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 Feb 27, 2020
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 Feb 27, 2020
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 Feb 27, 2020
Plan the resident's discharge to meet the resident's goals and needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
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, patternCorrected Feb 27, 2020
Provide safe and appropriate respiratory care for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
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, patternCorrected Feb 27, 2020
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
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 Feb 27, 2020
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Ensure that residents are free from significant medication errors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
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 Feb 27, 2020
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 27, 2020
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 16, 2020
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 16, 2020
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 16, 2020
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 16, 2020
Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 Feb 27, 2020
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 Feb 27, 2020
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 Feb 27, 2020
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Provide appropriate foot care.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Have exits that are accessible at all times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
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 Jan 16, 2020
Have properly located and lighted "Exit" signs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Meet other general requirements that are deficient.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Have an enclosure around a vertical opening shaft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Meet requirements for the use of electrical equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 Feb 27, 2020
Establish emergency prep training and testing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Establish staff and initial training requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Conduct testing and exercise requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 16, 2020
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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, isolatedCorrected Feb 27, 2020
Ensure a qualified health professional conducts resident assessments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Assure that each resident’s assessment is updated at least once every 3 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
Provide or obtain dental services for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2020
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 B of L: potential for minimal harm, patternCorrected Feb 27, 2020