Have simulated fire drills held at unexpected times.
Severity L of L: immediate jeopardy, widespreadCorrected May 31, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
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 May 24, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 12, 2024
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 Jun 12, 2024
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 Jun 12, 2024
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 Jun 7, 2024
Put firmly secured handrails on each side of hallways.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 10, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Include a process for Emergency Preparedness collaboration.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish policies and procedures including evacuation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish policies and procedures for sheltering.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish policies and procedures for medical documentation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish policies and procedures for volunteers.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Create arrangements with other facilities to receive patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Develop a communication plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
List the names and contact information of those in the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Provide emergency officials' contact information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Provide primary/alternate means for communication.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish methods for sharing information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Provide a means of sharing information on occupancy/needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Provide family notifications of emergency plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
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 May 31, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 12, 2024
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2024
Have restrictions on the use of flammable curtains.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 4, 2024
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 May 31, 2024
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 12, 2024
Have horizontal exits used in accordance with safety requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 31, 2024
Install proper backup exit lighting.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 31, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 31, 2024
Ensure that testing and maintenance of electrical equipment is performed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 12, 2024
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 Jun 14, 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 May 31, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 31, 2024
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 31, 2024
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 31, 2024
Have properly located and lighted "Exit" signs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 31, 2024
Meet requirements for sections of health care facilities separated by fire resistive construction.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 31, 2024
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity C of L: potential for minimal harm, widespreadCorrected May 17, 2024
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 C of L: potential for minimal harm, widespreadCorrected May 17, 2024
Provide activities to meet all resident's needs.
Severity C of L: potential for minimal harm, widespreadCorrected May 31, 2024