Install an approved automatic sprinkler system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 1, 2024
Install a fire alarm system that can be heard throughout the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 1, 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 Aug 3, 2024
Post nurse staffing information every day.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 3, 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, patternFound during a complaint inspectionCorrected Aug 3, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 3, 2024
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 3, 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 Aug 3, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 3, 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, patternFound during a complaint inspectionCorrected Aug 3, 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 Aug 3, 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 Aug 3, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
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, isolatedFound during a complaint inspectionCorrected Sep 20, 2024
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 20, 2024
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
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, isolatedFound during a complaint inspectionCorrected Aug 3, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
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 Aug 3, 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 Aug 3, 2024
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
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 Aug 3, 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, isolatedFound during a complaint inspectionCorrected Aug 3, 2024
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 3, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
Implement a program that monitors antibiotic use.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 3, 2024
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 2024