Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 7, 2021
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 Jul 7, 2021
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 Jul 7, 2021
Perform COVID19 testing on residents and staff.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 7, 2021
Assure that each resident’s assessment is updated at least once every 3 months.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
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, patternCorrected Jul 7, 2021
Ensure the activities program is directed by a qualified professional.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
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, patternCorrected Jul 7, 2021
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 7, 2021
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 7, 2021
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 Jul 7, 2021
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 7, 2021
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 Jul 7, 2021
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 Jul 7, 2021
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 7, 2021
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 7, 2021
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 7, 2021
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, isolatedCorrected Jul 7, 2021
