Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity L of L: immediate jeopardy, widespreadCorrected Feb 7, 2024
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 7, 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 Feb 7, 2024
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
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 Feb 7, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
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 Feb 7, 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 Feb 7, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
Hire a qualified full-time social worker in a facility with more than 120 beds.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2024
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Post nurse staffing information every day.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 2024
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 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 Feb 7, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 2024
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 2024
