Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 29, 2024
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 14, 2024
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 Apr 12, 2024
Properly provide smoke detection systems in areas open to corridors.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 29, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Dispose of garbage and refuse properly.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
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 May 14, 2024
Post nurse staffing information every day.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
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 12, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Provide activities to meet all resident's needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
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 Apr 12, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 29, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 12, 2024
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, isolatedCorrected Apr 12, 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 12, 2024
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, isolatedCorrected Apr 12, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 12, 2024
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 12, 2024
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 12, 2024
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 Apr 12, 2024
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 14, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 12, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Have approved installation, maintenance and testing program for fire alarm systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 29, 2024
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity B of L: potential for minimal harm, patternCorrected Apr 12, 2024