Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Nov 29, 2023
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 6, 2023
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 Dec 6, 2023
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Have properly installed electrical wiring and gas equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 6, 2023
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 Dec 6, 2023
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Have an enclosure around a vertical opening shaft.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 6, 2023
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Have proper medical gas storage and administration areas.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 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 Nov 27, 2023
Have policies on smoking.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 29, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Nov 29, 2023
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 Nov 29, 2023
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 29, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Nov 29, 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 Nov 29, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 6, 2023
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Have exits that are accessible at all times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2023
Have power receptacles that are properly grounded.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2023
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 Nov 29, 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 Nov 29, 2023
Use approved construction type or materials.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 6, 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 Dec 6, 2023
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 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 Nov 27, 2023
Construct fire resistant interior walls.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2023
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2023
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 Nov 29, 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 Nov 29, 2023
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 29, 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 Dec 6, 2023
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 29, 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 Nov 29, 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 Nov 29, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 29, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 29, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 29, 2023
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, isolatedCorrected Nov 29, 2023
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 29, 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 Nov 29, 2023