Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Jul 20, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity G of L: actual harm, isolatedCorrected Sep 14, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 23, 2023
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 Sep 14, 2023
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 Sep 14, 2023
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 Aug 23, 2023
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 23, 2023
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 23, 2023
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 23, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 14, 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 Sep 14, 2023
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 23, 2023
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 23, 2023
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 Aug 23, 2023
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 23, 2023
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, isolatedFound during a complaint inspectionCorrected Sep 14, 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 Sep 14, 2023
Plan the resident's discharge to meet the resident's goals and needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 2023
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 2023
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 2023
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 Sep 15, 2023
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 Sep 14, 2023
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 Sep 14, 2023
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, isolatedCorrected Sep 14, 2023
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 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 Sep 14, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 2023
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 Sep 14, 2023
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 14, 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 Sep 14, 2023
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 Sep 14, 2023
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 14, 2023
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 14, 2023
Have approved installation, maintenance and testing program for fire alarm systems.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 23, 2023
Install emergency lighting that can last at least 1 1/2 hours.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 23, 2023
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 Sep 14, 2023
Have proper medical gas storage and administration areas.
Severity B of L: potential for minimal harm, patternCorrected Aug 23, 2023
