Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity H of L: actual harm, patternCorrected Apr 4, 2024
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 4, 2024
Ensure residents have reasonable access to and privacy in their use of communication methods.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 4, 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 F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 4, 2024
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 F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 4, 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, widespreadFound during a complaint inspectionCorrected Apr 4, 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, widespreadFound during a complaint inspectionCorrected Apr 4, 2024
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 4, 2024
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 4, 2024
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 26, 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 Mar 4, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 4, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 15, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 22, 2024
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 Mar 4, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 23, 2024
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 23, 2024
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 23, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 29, 2024
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 4, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 23, 2024
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 4, 2024
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, patternFound during a complaint inspectionCorrected Apr 4, 2024
Provide care or services that was trauma informed and/or culturally competent.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 4, 2024
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, patternFound during a complaint inspectionCorrected Apr 4, 2024
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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 4, 2024
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, patternFound during a complaint inspectionCorrected Apr 4, 2024
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, isolatedFound during a complaint inspectionCorrected Apr 4, 2024
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 4, 2024
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, isolatedFound during a complaint inspectionCorrected Apr 4, 2024
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, isolatedFound during a complaint inspectionCorrected Apr 4, 2024
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, isolatedFound during a complaint inspectionCorrected Apr 4, 2024