Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Oct 14, 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 Oct 1, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 1, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 1, 2024
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 1, 2024
Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 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 Oct 1, 2024
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 14, 2024
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 1, 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 Nov 14, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 1, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 14, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 14, 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 Oct 14, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 14, 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, patternCorrected Oct 14, 2024
Respond appropriately to all alleged violations.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 14, 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, patternFound during a complaint inspectionCorrected Oct 14, 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, patternFound during a complaint inspectionCorrected Oct 14, 2024
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 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 Oct 1, 2024
Properly provide smoke detection systems in areas open to corridors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Meet other general requirements that are deficient.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 2024
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 14, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 2024
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 14, 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 Oct 14, 2024
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 2024
Observe each nurse aide's job performance and give regular training.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 2024
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 1, 2024
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 1, 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 Nov 14, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 14, 2024
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 14, 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 Oct 14, 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 Oct 14, 2024
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 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, isolatedFound during a complaint inspectionCorrected Oct 14, 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, isolatedFound during a complaint inspectionCorrected Oct 14, 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 Oct 14, 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 Oct 14, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 14, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 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 Oct 14, 2024
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 14, 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, isolatedFound during a complaint inspectionCorrected Oct 14, 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 Oct 14, 2024
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 14, 2024
