Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 16, 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 Jul 16, 2024
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 31, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 16, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 16, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 16, 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 Jul 16, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 31, 2024
Protect each resident from the wrongful use of the resident's belongings or money.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 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, isolatedCorrected Jul 16, 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, isolatedCorrected Jul 16, 2024
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 16, 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 Jul 16, 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 Jul 16, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
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 16, 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, isolatedCorrected Jul 16, 2024
Provide routine and 24-hour emergency dental care for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
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 Jul 16, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 16, 2024
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 Jul 16, 2024