Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Install proper backup exit lighting.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Have simulated fire drills held at unexpected times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2023
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 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 22, 2023
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 May 22, 2023
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2023
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 May 22, 2023
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2023
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, isolatedCorrected May 22, 2023
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 May 22, 2023
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 May 22, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 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 22, 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 22, 2023
Have properly located and lighted "Exit" signs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2023
Have approved installation, maintenance and testing program for fire alarm systems.
Severity C of L: potential for minimal harm, widespreadCorrected May 22, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity C of L: potential for minimal harm, widespreadCorrected May 22, 2023
