Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 27, 2024
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 May 27, 2024
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 22, 2024
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 Apr 22, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 22, 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 22, 2024
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 22, 2024
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 27, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 27, 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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 22, 2024
Protect each resident from the wrongful use of the resident's belongings or money.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 22, 2024
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 22, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 22, 2024
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, patternFound during a complaint inspectionCorrected Apr 22, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 22, 2024
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 27, 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 May 27, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 27, 2024
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 27, 2024
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
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 22, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
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 22, 2024
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 22, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
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, isolatedFound during a complaint inspectionCorrected Apr 22, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 22, 2024
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 C of L: potential for minimal harm, widespreadFound during a complaint inspectionCorrected Apr 22, 2024