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 Sep 30, 2024
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Have proper medical gas storage and administration areas.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 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 Sep 30, 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 Sep 30, 2024
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 30, 2024
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 30, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2024
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 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, isolatedCorrected Sep 30, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2024
Give the resident's representative the ability to exercise the resident's rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 30, 2024
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2024
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 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 Sep 30, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 30, 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, isolatedFound during a complaint inspectionCorrected Sep 30, 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 Sep 30, 2024
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2024