Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 16, 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 May 16, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 16, 2024
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 16, 2024
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 16, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 16, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 16, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 16, 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 May 16, 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 May 16, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 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 May 15, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 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 May 15, 2024
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 2024
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 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 May 15, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 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 May 15, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 15, 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 May 15, 2024
Have simulated fire drills held at unexpected times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 16, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected May 16, 2024