Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 9, 2023
Dispose of garbage and refuse properly.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 9, 2023
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 9, 2023
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 9, 2023
Install an approved automatic sprinkler system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 25, 2023
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 25, 2023
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 25, 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, patternCorrected May 9, 2023
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 May 9, 2023
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 May 9, 2023
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 2023
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 May 9, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 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, patternCorrected May 9, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 2023
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 May 9, 2023
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 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, patternCorrected May 9, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 2023
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 May 9, 2023
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 May 9, 2023
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 2023
Keep complete, dated laboratory records in the resident's record.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2023
Provide or obtain dental services for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2023
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2023
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 May 9, 2023
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 May 9, 2023
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2023
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 May 9, 2023
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2023
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2023
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 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, isolatedCorrected May 9, 2023
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 May 9, 2023
