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 Apr 29, 2025
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 29, 2025
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
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 Apr 29, 2025
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
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 Apr 29, 2025
Have power receptacles that are properly grounded.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
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 Apr 29, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Meet other general requirements that are deficient.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
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 Apr 29, 2025
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Establish policies and procedures including evacuation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 29, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 29, 2025
Keep residents' personal and medical records private and confidential.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 29, 2025
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 29, 2025
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, patternFound during a complaint inspectionCorrected Apr 29, 2025
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, patternFound during a complaint inspectionCorrected Apr 29, 2025
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 29, 2025
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 Apr 29, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
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, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
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, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 29, 2025
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity B of L: potential for minimal harm, patternFound during a complaint inspectionCorrected Apr 29, 2025