Provide and implement an infection prevention and control program.
Severity L of L: immediate jeopardy, widespreadCorrected Apr 23, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 23, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 23, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 23, 2025
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 Apr 23, 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, patternCorrected Apr 23, 2025
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 Apr 23, 2025
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 23, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 23, 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, isolatedCorrected Apr 23, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 23, 2025
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
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 Apr 23, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 23, 2025
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, isolatedCorrected Apr 23, 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, isolatedCorrected Apr 23, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 23, 2025
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, isolatedCorrected Apr 23, 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 23, 2025
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
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 Apr 29, 2025
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 B of L: potential for minimal harm, patternCorrected Apr 23, 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, patternCorrected Apr 23, 2025
